A 25-year-old female was brought to the emergency department with a history of nausea, vomiting, dizziness, abdominal pain, and altered sensorium. She was weighing around 55 kgs. She had given history of ingestion of two bottles (refills) of mosquito repellent available in the house, 2 h before she was brought to the hospital. (Each refill containing 45 ml (396 mg) transfluthrin). On examination, patient was conscious, pupils bilaterally semi constricted and sluggishly reactive to light. On auscultation of lungs crepitations were present bilaterally. Respiratory rate was 28/min. Blood pressure was 110/70 mmHg. In emergency ward, gastric lavage was performed and then continuous gastric aspiration was started through Ryles tube. Oral syrup charcoal 10 ml was given, and Ryles tube was closed at proximal end for some time. Then again aspiration through Ryles tube was continued. Atropine 0.6 mg, pantoprazole 40 mg and ondansetron 4 mg were given intravenously. Tonic-clonic convulsions were observed after 1 h of admission in the emergency ward. Injection phenytoin 700 mg bolus, injection diazepam 10 mg, injection hydrocortisone 100 mg, injection frusemide 20 mg, were administered intravenously. Oxygen enrichment was continued. However, patient had continuous uncontrolled convulsions. Then patient was shifted to intensive care unit and midazolam 5 mg and propofol 100 mg (80 mg + 20 mg) were administered intravenously. Endotracheal intubation was successfully performed with 7.5 mm ID endotracheal tube, and cuff was inflated and oxygen enrichment at 4–6 L/min via T-piece was initiated. Midazolam 4 mg/h and propofol 200 mg/h IV infusions were started. SpO2 was maintained at 100%. Blood pressure was 94/62 mmHg. Pulse rate was 74/min. Arterial blood gas (ABG) reports were normal. Neurophysician advised IV mannitol (20%)100 ml twice a day and IV phenobarbitone (SOS) for seizures.\nPatient was seizure free for few hours but again seizures started, and not controlled even with repeat doses of phenytoin, midazolam, propofol, and phenobarbitone. At that time blood pressure was 80/40 mm of Hg, respiratory rate was 35/min, pulse rate was 190/min, and SpO2 was 95%. Serum potassium, calcium, and sodium were 2.98 mmol/L, 2.5 mmol/L and 129 mmol/L, respectively. Injection dopamine was started at 10 μgm/kg/min. Potassium chloride 1.5 g and hypertonic saline were administered. Despite repeated doses of phenytoin, midazolam, propofol and phenobarbitone, seizures were not controlled. Elective ventilation was planned after muscle paralysis to control seizures. Patient was paralyzed by injection vecuronium 4 mg bolus and 4 mg/h IV infusion , and put on controlled mechanical ventilation (CMV) mode for elective ventilation. Vecuronium was continued at 4 mg/h. Blood pressure further decreased gradually and dopamine dose was increased and propofol infusion was stopped. ABG reports did not show any changes. Computed tomography scan of brain and chest X-ray were normal. Input/output charting for fluids was maintained. Central venous pressure remained at 5-8 cm H2O. Patient was kept on a ventilator for 48 h electively and then gradually weaning started. Vecuronium and midazolam infusion were stopped, and mode of ventilation was changed to synchronized intermittent mandatory ventilation (SIMV). Airway pressure support was set to 15 cm H2O with positive end expiratory pressure of 4 cm H2O. Patient's pulse rate was 102 beats/min, blood pressure 132/82 mmHg and SpO2 remained above 96%.\nPatient had total leucocyte count on day 1 of 7200/mm3 and it increased to 22,000/mm3 on the day 2, 32,000/mm3 on the day 3 and 13,000/mm3 on the day 4, all with neutrophilia without other signs of septicaemia, although antibiotics were continued. The counts decreased to 4000/mm3 on day 6. After 48 h on ventilator, dopamine infusion was tapered down in next 6 h and then stopped. About 6 h on SIMV mode, spontaneous respiration was noticed at 16 breaths/min. Muscle relaxation was reversed with inj. neostigmine 2.5 mg and inj.glycopyrrolate 0.4 mg. Patient started breathing spontaneously with adequate tidal excursion and followed verbal commands and then extubated. Oxygen through mask was given at flow of 4–5 L/min. Respiratory rate was 25 breaths/min, blood pressure was 108/72 mmHg and pulse rate, 119/min. Pupils were normally reacting to light. Patient was nebulised with mistabron 3 mg, repeated 8 hourly. Patient was referred to psychiatrist for counselling. On the day 4, patient was shifted to ward and discharged uneventful from hospital on 7th day.
The patient was a 16-month-old boy who was admitted to our hospital’s emergency department with a 15-min history of nausea, shortness of breath, and dyspnea. He subsequently developed cyanosis and impairment of consciousness. Foreign body inhalation had initially been diagnosed and the Heimlich maneuver served as the urgent treatment, but no foreign body was coughed up. On physical examination, he was unconscious, bilateral pupil diameter was 3 mm and sluggishly reactive to light. He exhibited rapid and shallow breathing with nasal flaring. The three concave signs were positive. Lung auscultation revealed clear breath sounds present bilaterally. His pulse rate was 161 per minute, and the blood pressure was 75/35 mmHg. Generalized tonic-clonic convulsions were observed after 5 min of admission in the emergency ward. 10% chloral hydrate 5 ml (5 mg/kg) was firstly administered via enema. After intravenous access was available, 2 mg midazolam was administered intravenously twice with intervals of 5 min, as well as intramuscular injection of phenobarbital 0.1 g. Despite of these interventions, the patient kept having uncontrolled convulsions for about 35 min, then 20 mg propofol by intravenous infusion was given to finally control his seizures. The patient’s trachea was intubated during the treatment, and then he was transferred to the intensive care unit for mechanical ventilation. During the hospitalization, meperfluthrin poisoning was considered when his parents provided a critical information that they found an empty liquid mosquito repellent bottle (Jiaojie®) in the location where the patient’s symptoms onset. According to the instruction, nearly 30 ml of meperfluthrin containing 8 mg / ml, total dose of 240 mg, was ingested.\nAfter hospitalization, he presented with fever and had a total leucocyte count of 23,600/mm3 and C-reactive protein (CRP) of 116.4 mg/L on day 1. The chest radiograph (as arrowed in Fig. a) only revealed a little bilateral pulmonary exudate. Serum electrolytes, lactate dehydrogenase (LDH), creatine phosphokinase (CRK), alanine aminotransferase, aspartate aminotransferase and creatinine level were normal. Cholinesterase was 6188 U/L. Initial arterial blood gas (ABG) analysis showed pH 7.218, pO2 76 mmHg, pCO2 48.1 mmHg, HCO3 19.6 mmol/L, base excess − 8 mmol/L, plasma lactate 4.28 mmol/L. Cerebrospinal fluid (CSF) analysis and cranial computed tomography (CT) showed no abnormalities. On the second day of hospitalization, X-ray chest radiograph (as arrowed in Fig. b) showed multiple patchy and cord-like high-density shadows in the lungs bilaterally. Meanwhile, auscultation of the lungs revealed coarse crackles and wheezes. On day 3, Chest CT (Fig. ) revealed consolidation and atelectasis in the lower lobe of right lung and upper lobe of left lung, and multiple striated exudation could be seen in both lungs. On day 5, his X-ray chest radiograph (as arrowed in Fig. c) displayed consolidation and atelectasis in the right lower lobe and left upper lobe. His brain magnetic resonance imaging (MRI) (as arrowed in Fig. ) showed abnormal signal beside the anterior horn of the right lateral ventricle, and electroencephalogram (EEG) showed the diffused 2.0–4.0 Hz slow wave activity. Fiberoptic bronchoscopy revealed edema and congestion of mucous membrane without erosion or ulcers. The sputum culture gave a positive result for Hemophilus influenzae.\nAccording to the clinical symptoms, laboratory results and imaging findings, the patient was diagnosed with meperfluthrin poisoning, status epilepticus and severe pneumonia. Methylprednisolone (1 mg/kg every 12 h) by intravenous drip infusion and aerosolized beclomethasone dipropionate were prescribed to reduce pulmonary inflammation. Cefoperazone-sulbactam (60 mg/kg every 8 h) was administrated to control lung infection. Mannitol and monosialoteterahexosyl ganglioside were used to reduce intracranial pressure and protect injured nerve cells. He was successfully weaned off from the ventilator on day 15. Routine blood tests and CRP revealed no abnormalities after retesting. After a recheck on day 20, the chest X-ray radiograph (Fig. d) showed a significant improvement of the bilateral pulmonary exudate. After obvious symptoms relief, he was transferred to the rehabilitation department and the hyperbaric oxygen therapy was utilized for further neural repair. After a psychiatric consultation, he was discharged from the hospital on day 30. No symptoms had occurred after 12 months of follow up. The chronology of events was showed in Table .