Unexpected cholinergic crisis caused by distigmine bromide: A case report.

Abstract

RATIONALE:

Distigmine bromide is a cholinesterase (ChE) inhibitor used to treat dysuria due to a hypotonic bladder. We encountered a case of cholinergic crisis caused by distigmine bromide, which resulted in a rapid decrease in serum ChE levels, hypothermia, respiratory failure, and circulatory failure within a short period of time.

PATIENT CONCERNS:

A 51-year-old man was admitted to a psychiatric hospital to treat behavioral disorders due to irritability and violent behavior. The patient was referred to our hospital for septic shock secondary to urinary tract infection and respiratory failure. He had not defecated for 5 days before visiting our hospital. He had moderate intellectual disability. Immediately after admission, he developed hand tremors and drooling. The airway was obstructed by drooling due to vomiting of yellow clear gastric juice.

DIAGNOSIS:

The patient's high saliva volume, bradycardia, respiratory failure (54 breaths/min), constricted pupils (2.5/mm), poor oxygenation, and a history of oral medication were consistent with the diagnosis of cholinergic crisis due to distigmine bromide.

INTERVENTIONS:

On admission, the patient was immediately intubated. He was treated with noradrenaline (0.1 µg/kg/min) to increase his blood pressure. He was admitted to the intensive care unit (ICU). Since he had circulatory failure, vasopressin (approximately 1 U/h) was administered. Continuous intravenous atropine sulfate (0.6 mg/h) was also administered for high saliva volume.

OUTCOMES:

On the 8th ICU day, the patient's drooling and bradycardia improved. The patient was physically and mentally stable, and transferred to the referring hospital.

LESSONS:

ChE levels and symptoms before onset may not be useful for the early detection and prevention of adverse effects of cholinergic crisis caused by distigmine bromide. In addition to known risks such as renal impairment and older age, constipation should be recognized and communicated as a risk factor.

• Authors: Toshiki Sera, Shinji Kusunoki, Nobuaki Shime
• Journal: Medicine (Medicine (Baltimore)) Vol. 101 Issue 47 Pg. e31677 (Nov 25 2022) ISSN: 1536-5964 [Electronic] United States
• PMID: 36451415 (Publication Type: Case Reports, Journal Article)
• Copyright: Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.

Chemical References

• distigmine
• Cholinesterase Inhibitors

Topics

• Male
• Humans
• Middle Aged
• Bradycardia
• Sialorrhea
• Cholinesterase Inhibitors (adverse effects)
• Respiratory Insufficiency (chemically induced)