Thursday, March 29, 2012


A farmer presents with the chief complaint, "I have fluids gushing out of every orifice." Ew. He has nausea, vomiting, diarrhea, urinary incontinence, sweating, lacrimation, and salivation. On exam, you note bradycardia with a heart rate of 42, miosis, and wheezing. On review of systems, the patient has some subjective muscle weakness. EKG shows heart block and QT prolongation. Atropine 1mg IV is administered with little effect on the heart rate.

The patient is admitted to the hospital. Due to the fascinating findings, both neurology and internal medicine want to be the primary service. About 24-96 hours later, the patient develops neck flexion weakness, decreased deep tendon reflexes, cranial nerve abnormalities, proximal muscle weakness, and respiratory insufficiency. Now, neither internal medicine nor neurology wants the patient so he goes to ICU. After two weeks in the ICU including a stint on the mechanical ventilator, the patient has complete resolution of his neurologic symptoms.

Challenge: What's your diagnosis?

Image is in the public domain.


Anonymous said...

SLUDGE syndrome due to exposure to organophosphate pesticide.

Reflex Hammer said...

Organophosphate poisoning

Anonymous said...

organophosphate poisoning?

Anonymous said...

Well, obvious organophosphate poisoning with extended complications.

I'm guessing some of the complications are from extended exposure to the organophosphates, and possibly pre-existing respiratory problems.

I would be interested to see what the continued treatment was for this patient as well as what any abnormal lab values were.


Craig Chen said...

nice responses!

This is organophosphate poisoning causing severe cholinergic toxicity by inhibiting acetylcholinesterase. The acute manifestations and intermediate syndrome are described here. Treatment is with high doses of atropine, pralidoxime, benzodiazepines for seizures, and decontamination.

Sources: UpToDate; Wikipedia.