Critical Care: Student/Resident Case Report Poster - Critical Care II |

Malathion Madness FREE TO VIEW

Nirmala Surapaneni, MD; Brent Tatsuno, MD; David Silberstein, MD
Author and Funding Information

Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):399A. doi:10.1016/j.chest.2016.08.412
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SESSION TITLE: Student/Resident Case Report Poster - Critical Care II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Toxidromes make up a small but significant proportion of ICU admissions. Prompt recognition is important in order to treat the patient appropriately. Here we present a case of an inadvertent organophosphate intoxication due to extreme delusions.

CASE PRESENTATION: A 45 year old male was found unconscious in his van surrounded by Pinesol, Malathion bug spray, and drug paraphernalia. He was confused with pinpoint pupils, copious secretions, incontinence, and sores on his face. His labs were remarkable for an elevated WBC, lactate and CK. He developed pulmonary edema and was intubated. Given his symptoms and the presence of Malathion in the van, organophosphate toxicity was suspected. Supportive measures including atropine and pralidoxime were given and he gradually improved. His labs later showed decreased RBC and plasma cholinesterase. Coincidentally, his girlfriend was also admitted with vomiting and diarrhea and was able to provide a history. The patient had a botfly removed from a sore on his face one year ago. Fearing larval infestation, he purchased Malathion from Craigslist, injected it into his sores, and covered them with crazy glue. He also heavily fumigated his van to kill any insects.

DISCUSSION: Organophosphate toxicity is uncommon in the United States, and Malathion, a commonly used pesticide, is one of the safest organophosphates due to its selective toxicity profile. Dermal exposure to Malathion has a lower exposure threshold for adverse events than inhalation. Organophosphates irreversibly inhibit acetylcholinesterase, resulting in pooling of acetylcholine at the muscarinic and nicotinic receptors. Symptoms of cholinergic excess include diarrhea, urination, miosis, bronchorrhea, bradycardia, emesis, lacrimation, and salivation (DUMBELLS). Diagnosis is based around the toxidrome and treatment is supportive, including atropine to decrease bronchial secretions and pralidoxime for respiratory muscle weakness. In severe situations, patients can have delayed neuropathy, or suffer from Intermediate Syndrome which may reflect inadequate treatment. Most patients, however, improve once the toxin leaves the system.

CONCLUSIONS: Organophosphate toxicity should be recognized quickly to initiate proper treatment. Due to its safe profile, Malathion toxicity is rare. In this case, because of his delusions, our patient was exposed to Malathion by dermal injection and inhalation. Anticholinergic medications including atropine and pralidoxime were used to treat the patient’s organophosphate toxicity.

Reference #1: Eddleston M, Buckley NA, Eyer P, et al. Management of acute organophosphorus pesticide poisoning. Lancet. 2008; 371: 597-607.

Reference #2: Hulse EJ, Davies JOJ, Simpson AJ, et al. Respiratory complications of organophosphorous nerve agent and insecticide poisoning. American Journal of Respiratory and Critical Care Medicine. 2014; 190 (12): 1342-54.

Reference #3: King AM, Aaron CK. Organophosphate and carbamate poisoning. Emergency Medicine Clinic of North America. 2015; 33: 133-51.

DISCLOSURE: The following authors have nothing to disclose: Nirmala Surapaneni, Brent Tatsuno, David Silberstein

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