Delayed-onset status epilepticus without cholinergic features in organophosphate poisoning: a case report
Background: Organophosphates (OPs) exert their toxic effects by inhibiting acetylcholinesterase in both central (CNS) and peripheral nervous systems (PNS), resulting in accumulation of acetylcholine and overstimulation of cholinergic synapses. Seizures associated with OP poisoning typically occur in...
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Elsevier
2025-12-01
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| author | Shayani Vimalanathan Pramith Ruwanpathirana Thashi Chang |
| author_facet | Shayani Vimalanathan Pramith Ruwanpathirana Thashi Chang |
| author_sort | Shayani Vimalanathan |
| collection | DOAJ |
| description | Background: Organophosphates (OPs) exert their toxic effects by inhibiting acetylcholinesterase in both central (CNS) and peripheral nervous systems (PNS), resulting in accumulation of acetylcholine and overstimulation of cholinergic synapses. Seizures associated with OP poisoning typically occur in the context of overt systemic cholinergic manifestations. We report a patient with OP poisoning who developed status epilepticus without developing peripheral cholinergic features. Case presentation: A 40-year-old Sri Lankan man presented six hours after deliberate ingestion of 50 mL of profenofos (500 g/L emulsifiable concentrate). His past medical history was unremarkable. There was no history of substance misuse. On admission, he was conscious, haemodynamically stable, and did not have signs of cholinergic excess. Thirty-six hours post-ingestion, he developed generalized tonic–clonic seizures, which were refractory to intravenous (IV) midazolam boluses and IV levetiracetam. He was intubated and mechanically ventilated. Continuous electroencephalographic monitoring confirmed termination of seizure activity with an intravenous midazolam infusion. Atropine was administered empirically for possible central cholinergic toxicity. The patient made a full neurological recovery and was successfully extubated 72 h after ingestion. The patient remained asymptomatic in a six month follow up. Conclusion: This case illustrates an uncommon presentation of OP poisoning: delayed-onset status epilepticus in the absence of peripheral cholinergic features. The high lipophilicity of profenofos may facilitate preferential accumulation in the CNS, leading to a predominantly central cholinergic syndrome. This underscores the importance of recognising atypical neurotoxic presentations of OP poisoning and the potential need for CNS-directed therapy even in the absence of classic peripheral signs. |
| format | Article |
| id | doaj-art-fd47d1df3b7d4e5bb1f38e9f74fa6447 |
| institution | Kabale University |
| issn | 2214-7500 |
| language | English |
| publishDate | 2025-12-01 |
| publisher | Elsevier |
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| series | Toxicology Reports |
| spelling | doaj-art-fd47d1df3b7d4e5bb1f38e9f74fa64472025-08-20T04:02:26ZengElsevierToxicology Reports2214-75002025-12-011510210610.1016/j.toxrep.2025.102106Delayed-onset status epilepticus without cholinergic features in organophosphate poisoning: a case reportShayani Vimalanathan0Pramith Ruwanpathirana1Thashi Chang2Professorial Unit in Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka; Flinders Medical Centre, Bedford Park SA 5042, AustraliaProfessorial Unit in Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka; Flinders Medical Centre, Bedford Park SA 5042, Australia; Corresponding author at: Professorial Unit in Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka.Professorial Unit in Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka; Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka; Flinders Medical Centre, Bedford Park SA 5042, AustraliaBackground: Organophosphates (OPs) exert their toxic effects by inhibiting acetylcholinesterase in both central (CNS) and peripheral nervous systems (PNS), resulting in accumulation of acetylcholine and overstimulation of cholinergic synapses. Seizures associated with OP poisoning typically occur in the context of overt systemic cholinergic manifestations. We report a patient with OP poisoning who developed status epilepticus without developing peripheral cholinergic features. Case presentation: A 40-year-old Sri Lankan man presented six hours after deliberate ingestion of 50 mL of profenofos (500 g/L emulsifiable concentrate). His past medical history was unremarkable. There was no history of substance misuse. On admission, he was conscious, haemodynamically stable, and did not have signs of cholinergic excess. Thirty-six hours post-ingestion, he developed generalized tonic–clonic seizures, which were refractory to intravenous (IV) midazolam boluses and IV levetiracetam. He was intubated and mechanically ventilated. Continuous electroencephalographic monitoring confirmed termination of seizure activity with an intravenous midazolam infusion. Atropine was administered empirically for possible central cholinergic toxicity. The patient made a full neurological recovery and was successfully extubated 72 h after ingestion. The patient remained asymptomatic in a six month follow up. Conclusion: This case illustrates an uncommon presentation of OP poisoning: delayed-onset status epilepticus in the absence of peripheral cholinergic features. The high lipophilicity of profenofos may facilitate preferential accumulation in the CNS, leading to a predominantly central cholinergic syndrome. This underscores the importance of recognising atypical neurotoxic presentations of OP poisoning and the potential need for CNS-directed therapy even in the absence of classic peripheral signs.http://www.sciencedirect.com/science/article/pii/S2214750025002252OrganophosphateProfenofosStatus epilepticusCholinergic toxidrome |
| spellingShingle | Shayani Vimalanathan Pramith Ruwanpathirana Thashi Chang Delayed-onset status epilepticus without cholinergic features in organophosphate poisoning: a case report Toxicology Reports Organophosphate Profenofos Status epilepticus Cholinergic toxidrome |
| title | Delayed-onset status epilepticus without cholinergic features in organophosphate poisoning: a case report |
| title_full | Delayed-onset status epilepticus without cholinergic features in organophosphate poisoning: a case report |
| title_fullStr | Delayed-onset status epilepticus without cholinergic features in organophosphate poisoning: a case report |
| title_full_unstemmed | Delayed-onset status epilepticus without cholinergic features in organophosphate poisoning: a case report |
| title_short | Delayed-onset status epilepticus without cholinergic features in organophosphate poisoning: a case report |
| title_sort | delayed onset status epilepticus without cholinergic features in organophosphate poisoning a case report |
| topic | Organophosphate Profenofos Status epilepticus Cholinergic toxidrome |
| url | http://www.sciencedirect.com/science/article/pii/S2214750025002252 |
| work_keys_str_mv | AT shayanivimalanathan delayedonsetstatusepilepticuswithoutcholinergicfeaturesinorganophosphatepoisoningacasereport AT pramithruwanpathirana delayedonsetstatusepilepticuswithoutcholinergicfeaturesinorganophosphatepoisoningacasereport AT thashichang delayedonsetstatusepilepticuswithoutcholinergicfeaturesinorganophosphatepoisoningacasereport |