Introduction. Intermediate syndrome (IMS) was described a few decades ago,
however, there is still a controversy regarding its exact etiology, risk
factors, diagnostic parameters and required therapy. Considering that acute
poisonings are treated in different types of medical institutions this
serious complication of organophosphate insecticide (OPI) poisoning is
frequently overlooked. The aim of this paper was to present a case of IMS in
organophosphate poisoning, which, we believe, provides additional data on the
use of oxime or atropine. Case report. After a well-resolved cholinergic
crisis, the patient developed clinical presentation of IMS within the first
72 h from deliberate malathion ingestion. The signs of IMS were weakness of
proximal limb muscles and muscles innervated by motor cranial nerves,
followed by the weakness of respiratory muscles and serious respiratory
insufficiency. Malathion and its active metabolite were confirmed by
analytical procedure (liquid chromatography-mass spectrometry). Pralidoxime
methylsulphate, adiministered as a continuous infusion until day 8 (total
dose 38.4 g), and atropine until the day 10 (total dose 922 mg) did not
prevent the development of IMS, hence the mechanical ventilation that was
stopped after 27 h had to be continued until the day 10. Conclusion.
Continuous pralidoxime methylsulphate infusion with atropine did not prevent
the development of IMS, most likely due to the delayed treatment and
insufficient oxime dose but also because of chemical structure and
lipophilicity of ingested OPI. A prolonged intensive care monitoring and
respiratory care are the key management for the intermediate syndrome.
Oxime and atropine failure to prevent intermediate syndrome development in acute organophosphate poisoning