A 16-year-old girl was admitted to the ICU with a history of consuming poison (20 ml of deltamethrin containing 12.5mg/ml, total dose = 250mg) following a domestic dispute. She presented with status epilepticus. As per the details gathered from the relatives, the patient was having continuous generalized tonic clonic seizures (GTCs) (status) since one hour prior to admission and was even convulsing during her transfer to the hospital. On arrival the patient was immediately intubated and ventilated and resuscitation started.\nThe convulsions were treated with injection Lorazepam, but there was no response. Further, doses of IV Midazolam/ Valproate/Phenobarbitone were given, but the convulsions continued. A bolus does of Thiopentone was then given, after which she stopped convulsing. She was started on a thiopentone infusion. Despite the thiopentone infusion, she had four episodes of GTCs in the next six hours, which were managed with further boluses of thiopentone (200mg) and increase in rate of the infusion. Inotropes were started and IV fluids were continued which were guided by CVP and arterial BP monitoring. Her rhythm on ECG was normal and lungs were clinically dry. CNS examination was not possible because she was sedated with thiopentone. Her pupils were dilated (6mm) and fixed.\nAn EEG showed 80% suppression of the brain. CT scan showed diffuse cerebral edema with effacement of sulci and chinking of lateral ventricles.\nLab reports showed normal S. cholinesterase levels (4340 IU/L), normal serum electrolytes and urine negative for myoglobin.\nAfter 48 hours of being on thiopentone infusion (24 hours without convulsions), she was weaned off thiopentone infusion. The patient was triggering the ventilator well by the next day (day 4). Supports were hence taken off gradually. The patient's pupils became reactive by day 5.\nIn the following days, the patient was tracheostomized (in view of anticipated prolonged mechanical ventilation) and T-piece trials were initiated soon. By day 11, she was opening eyes to call and was moving all four limbs, but with reduced power. Tracheostomy was decannulated on day 14 [].\nNerve conduction studies were done in view of her poor muscle strength which showed “severe, generalized, predominantly motor axonal polyneuropathy”.\nThe patient was shifted to the ward after 18 days of ICU stay, on supportive care. Wheelchair ambulation was started on day 21 and the patient was discharged on day 26.
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 .