Klorprifos Zehirlenmesini Takiben Gelişen Intermediate Sendromda Geç ve Aralıklı Oksim Tedavisi: Olgu Sunumu

Year 2015, Volume: 12 Issue: 3, 383 - 388, 30.12.2015

Başak Ceyda Meco Melek Tulunay, Esra Özayar Şaban Yalçın , Şirali Oba Necmettin Ünal Mehmet Oral

Abstract

İntermediate sendrom (İMS) proksimal ekstremite ve solunum kaslarında, boyun fleksorlarında ve kranial
sinirlerde zayıflıkla karakterizedir. Etyolojiyi açıklamak için birkaç hipotez geliştirilmiştir (nöromusküler
bileşke disfonksiyonu, yetersiz veya geç oksim tedavisi, asetilkolinesterazın uzamış ve ciddi inhibisyonu).
Klorprifos düşük toksisiteyle ilişkili organofosfattır. Klorprifosa sekonder İMS çok nadirdir. 56 yaşında
erkek hastada klorprifos oral alımından sonra gelişen İMS'u sunuyoruz. Başlangıçta kolinerjik sendrom
belirtileri gösteren hastada ikinci günde mental ve respiratuar durumu kötüleşip İMS'u düşündüren derin
motor paralizi gelişti. Hastaya ventilatör desteği gerekti. Pralidoksim geç (oral alımdan 52 saat sonra) ve 23 günde aralıklı olarak verilebildi. Hastanın takiplerinde ventilatör ilişkili pnömoni ve septik şok gelişmesine
rağmen 32. gününde taburcu edildi. Bu olgu klorprifos intoksikasyonlarıyla gelen hastalarda İMS riski
olduğunu göstermektedir.

Keywords

Zehirlenmeler, Klorprifos, Oksimler

Late and Interrupted Oxime Therapy In An Intermediate Syndrome Following Chlorpyrifos Poisoning: Case Report

Abstract

Intermediate syndrome (IMS) is characterized by weakness of proximal limb and respiratory muscles, neck
flexors, and cranial nerves. Several hypothesis have been developed to explain its etiology (neuromuscular
junction disfunction, inadequate or late oxime therapy, prolonged and severe inhibition of
acetylcholinesterase). Chlorpyrifos is a organophosphate with relatively low toxicity. IMS secondary to
chlorpyrifos is very rare. We report a case of 56-year-old man who developed an IMS after chlorpyrifos
ingestion. Although he presented with cholinergic symptoms initially, his mental and respiratory status
deteriorated and profound motor paralysis consistent with IMS occurred on the second day. The patient
required ventilatory support. Pralidoxime could only be administered late (52 hours post-ingestion), and
intermittently for 23 days. The course of the patient was complicated with ventilator-associated pneumonia
and septic shock, but after 32 days he was discharged. This case suggests that patients suffering from
chlorpyrifos intoxication can be under the risk of IMS. 

Keywords

Poisoning, Chlorpyrifos, Oximes

References

• 1-Peter JN, Moran JL, Graham PM. Oxime Therapy and Outcomes in Human Organophosphate Poisoning: An Evaluation Using Meta-analytic Techniques. Crit Care Med 2006;34(2): 502-10.
• 2-Tunçok Y, Hocaoğlu Aksay N. Organofosfatlı İnsektisidlerle Zehirlenme. Turkiye Klinikleri J Surg Med Sci 2006;2(46): 69-73.
• 3-Sungur M, Guven M. Intensive care management of organophosphate insecticide poisoning. Crit Care 2001;5(4): 211-15.
• 4-Yang CC, Deng JF. Intermediate syndrome following organophosphate insecticide poisoning. J Chin Med Assoc. 2007;70(11): 467-72.
• 5-Senayake N, Karalliedde L. Neurotoxic effects of organophosphorus insecticides: an intermediate syndrome. N Eng J Med 1987; 316(13): 761-63.
• 6-De Bleecker J, Van Den Neucker K, Willems J. The intermediate syndrome in organophosphate poisoning: presentation of a case and rewiev the literature. J Toxicol Clin Toxicol 1992; 30(4): 321-29.
• 7-De Bleecker J, Ven Den Neucker K, Colardyn F. Intermediate syndrome in organophosphorus poisoning: a prospective study. Crit Care Med 1993;21(11):1706- 11.
• 8-He Fu, Xu H, Qin F, Xu L, Huang J, He X. Intermediate myasthenia syndrome following acute organophosphates poisoning-an analysis of 21 cases. Hum Exp Toxicol 1998;17(1): 40-5.
• 9-Perayre Bedia M, Leiva Badose E, Pasto Cardona L, Jodar Massanes R. Intermediate syndrome after organophosphate poisoning despite continuous infusion of pralidoxime. An Med Interna 2007;24(3):129-31.
• 10-Wananukul W, Kiateboonsri S, Thithapandra A. The ''intermediate sydrome'' as critical sequelae of organophosphate poisoning: the first report of two cases in Thailand. J Med Assoc Thai 2005;88(9): 1308-13.
• 11-Mattingly JE, Sullivan JE, Spiller HA, Bosse GM. Intermediate syndrome after exposure to chlorpyrifos in a 16-month-old girl. J Emerg Med 2003;25(4): 379-81.
• 12-Bentur Y, Raikhlin-Eisenkraft B, Singer P. Beneficial late administration of obidoxime in malathion poisoning. Vet Hum Toxicol 2003;45(1):33-5.
• 13-Guadarrama-Naveda M, de Cabrera LC, MatosBastidas S. Intermediate syndrome secondary to ingestion of chlorpyrifos. Vet Hum Toxicol 2001;43(1): 34.
• 14-Lee F, Lin JL. Intermediate syndrome after organophosphate intoxication in patient with end-stage renal disease. Ren Fail 2006;28(2):197-200.
• 15-Karalliedde L, Baker D, Marrs TC. Organophosphateinduced intermediate syndrome: aetiology and relationships with myopathy. Toxicol Rev 2006;25(1):1- 14.
• 16-Eyer P. Neuropyschopatholojical changes by organophosphorus compounds: a review. Hum Exp Toxicol 1995;14(11): 857-64.
• 17-Khan S, Hemalatha R, Jeyaseelan L, Oommen A, Zachariah A. Neuroparalysis and oxime efficacy in o r g a n o p h o s p h a t e p o is o n i n g : a st u d y o f butyrylcholinesterase. Hum Exp Toxicol 2001;20(4): 169- 74.
• 18-Pawar K, Satish PK. Effectiveness of higher doses of pralidoxime ('PAM) 26 g in a day, in the treatment of organophosphosphorus poisoning: a randomised controlled trial. Lancet 2006; 368(9553):2136-41.
• 19-Barthold CL, Schier JG. Organic Phosphorus Compounds—Ne rve Agents. Crit Ca r e Clin 2005;21(4):673–89.
• 20-De Silva HJ, Wijewickrema R, Senanayake N. Does pralidoxime affect outcome in acute organophosphorus poisoning? Lancet. 1992;339(8802): 1136–8.
• 21-Peter JV, Moran JL, Graham P. Oxime therapy and outcomes in human organophosphate poisoning: an evaluation using meta-analitic techniques. Crit Care Med 2006;34(2):502-10.
• 22-Eddleston M, Singh S, Buckley N. Organophosphorus poisoning (acute). Clin Evid 2005; 13: 1745-55.
• 23-Eddleston M, Buckley NA, Eyer P, Dawson AH. Medical management of acute organophosphorus pesticide self-poisoning. Lancet 2008; 371(9612): 597-607.
• 24-Gaspari RJ, Paydarfar D.Pathophysiology of respiratory failure following acute dichlorvos poisoning in a rodent model. Neurotoxicology. 2007;28(3):664-71.
• 25-Noshad H, Ansarin K, Ardalan MR, Ghaffari AR, Safa J, Nezami N. Respiratory failure in organophosphat