A 13-year-old girl was admitted in our accident emergency with history of Bilbo 505 ingestion. The patient had ingested approximately 20 mL of Bilbo (chlopyrifos 50% and cypermethrin 5%) which was found to be a combination of OP and pyrethriod compound, with alkyl benzene sulfuric acid as emulsifier []. On arrival, the patient had difficulty in breathing which was accompanied by multiple episodes of vomiting. On examination, she was drowsy and had pinpoint pupils with an up-rolling of eye balls. There was no associated neck rigidity. Her heart rate was 92/min; peripheral oxygen saturation was 50%–70%, and auscultation of chest revealed bilateral crepitations, with excessive oral secretions. A chest radiograph revealed bilateral pulmonary infiltrates []. In view of her deteriorating clinical condition, the patient was intubated and mechanically ventilated. Gastric lavage was done to facilitate gastrointestinal decontamination. The patient received four doses of intravenous atropine, each of 6 mg. This was followed by administering atropine infusion at 6 mg/h till signs of atropinization were evident. Pralidoxime 2 g was administered intravenously in 100 mL of normal saline over 20 min, followed by repeat doses of 1 g pralidoxime four times a day. After an improvement in clinical course, tracheal extubation was done after 72 h of atropinization and pralidoxime administration. Her atropine dose was gradually tapered over the next 2 days and stopped thereafter.\nHowever, on day 7, she developed cough, breathlessness, and diarrhea for which she received oxygen supplementation, darolac sachet (containing lactobacillus sporegens), dextromethorphan hydrobromide, and chlorpheniramine maleate syrup. However, after 48 h (day 10), there was an increase in excessive frothy secretions from mouth, severe breathlessness, and diarrhea. It was accompanied by tachycardia and bilateral crepitations in both lung fields. She was immediately intubated, and considering the cholinergic symptoms of poisoning, atropine was restarted at an infusion of 3 mg/h. She responded rapidly to the antidote and was extubated uneventfully after 24 h. The dose of atropine was weaned-off by day 15. However, on day 18, the patient again had cholinergic symptoms characterized by miosis, excessive salivation, lacrimation, diarrhea, blurring of vision, and up-rolling of eyeballs. Atropine was restarted at low dose of 1.6 mg/h and the patient was asymptomatic. Simultaneously we sent her plasma and red blood cell cholinesterase and it was is in normal range. The patient was observed for prolonged poisoning effects and was kept under observation in a high dependency unit. She had few episodes of urinary incontinence, blurring of vision, and cough on day 25 of poisoning, which subsided without any further need of atropine administration. She had no new symptoms of lacrimation, bronchorrhea, and miosis. The patient was observed for few more days to look for delayed intermediate symptoms or rebound cholinergic symptoms. She was discharged after a month of poisoning and was being followed telephonically. Since the last telephonic contact, the patient was not known to have any symptoms and was living a healthy life.
Mr. A, a 22-year-old Hispanic male with past psychiatric history of methamphetamine dependence and bipolar disorder type 1, came to the emergency department because of suicidal ideation with a plan to slash his throat with a machete. The patient was very agitated in triage and during initial assessment. In the emergency room (ER), the patient reported that he had been using methamphetamine for the last two years. His last use was a few hours before coming to the ER and that was his only use during the past six to eight weeks.\nOn physical examination, temperature was found to be 96.5 degree Fahrenheit, pulse 105/minute, blood pressure 124/78 mm Hg, weight 68.0 kg, and height 173 cm. His pupils were 5 mm in diameter and reactive. In the review of systems, the patient denied any pulmonary, cardiac, renal, and abdominal complaints. There was no increased lacrimation. Lungs were clear and the heart rate was regular without murmurs. Bowel sounds were normoactive. The patient was not oriented to time. His affect was flat and irritable. He was evasive and tangential while answering questions. A chest radiograph and electrocardiogram were normal. His urinary drug screen was positive for amphetamines, methamphetamines, and cannabinoids. Blood chemistry concentrations/counts/percent of the following analyses were mainly within reference limits: alcohol <5 mg/dL, salicylate <4 mg/dL, sodium 141 mmol/L, potassium 3.8 mmol/L, chloride 107 mmol/L, blood urea nitrogen 10 mg/dL, creatinine 0.9 mg/dL, aspartate transaminase 23 U/L, alanine transaminase 18 U/L, alkaline phosphatase 69 U/L, thyroid stimulating hormone 0.57 μIU/mL, white blood cells 10.7 K/uL, red blood cells 4.49 Mu/L, haemoglobin 13.9 g/dL, hematocrit 42.2%, and platelets 239 K/uL. Urinalysis revealed nothing abnormal.\nThe patient was transferred to the inpatient psychiatry unit. The next day, the patient was disoriented, refused to talk to the treatment team, and slept most of the day. On his third hospital day, the patient was much more oriented and reported that he was unable to get methamphetamine for the past six to eight weeks because he could not afford it. He claimed to use an insecticide, mostly cockroach killer, to “get high.” He would either “electrocute” the bottle or spray it on a heated metal sheet, and when the contents of the bottle turned into crystal, he would either inhale it or smoke it. The patient would use the crystals formed from one bottle for four to seven days. He claimed that his friends used those crystals intravenously after diluting them. The patient reported that it would give him the same high as methamphetamine and he would occasionally have feelings of deja vu. The patient also reported having olfactory hallucinations when he was on “crystal roach killer” but could not elaborate on that. He said that he liked the increase in heart rate and the “rush” he used to get after every use.\nThe patient's last use of the “crystal roach killer” was three days before coming to the ER. The patient reported that he would sleep most of the day when he was using it. He denied unwanted adverse effects during his use except for frequent headaches upon waking up which were relieved by over-the-counter analgesics. The patient had been using the insecticide for six to eight weeks and only used methamphetamine one (1) day before coming to the ER. The patient claimed that he had been compliant with his medications for bipolar disorder until he started using “crystal roach killer.” The patient was taking divalproex sodium 500 mg twice daily and quetiapine extended-release 300 mg at bedtime. He voiced that he, since a few weeks before coming to the ER, got scared that he might get cancer because of the frequent use of the insecticide, which led him to have suicidal ideation.