Two Cases of Respiratory Failure After Recovery of Cholinergic Crisis in Organophosphate Poisoning: The Intermediate Syndrome

유기인제 중독에서 콜린성 위기 회복후 급성 호흡부전을 보인 Intermediate Syndrome 2예

Respiratory failure is the most serious manifestation and usual cause of death in acute organophosphate poisoning, and is common in acute cholinergic crisis. But the respiratory failure may appear suddenly in a patient who is recovering from the cholinergic crisis, even while receiving conventional therapy. These are case report of 37 years old male and 24 years old female with intermediate syndrome in organophosphate poisoning. The two patients ingested organophosphate(fenthion and mixture of DDVP with chlorpyrifos respectively) incidentally and in a sucide attempt respectively. After apparent recovery from the cholinergic crisis with a conventional therapy but before the expected onset of delayed polyneuropathy, the respiratory failure appeared suddenly with a muscular weakness, affecting predominantly the proximal limb muscles, neck flexors, territories of several motor cranial nerves. The two patients needed mechanical ventilatory support and recovery from the intermediate syndrome was complete in both patients, although one subsequently developed hypoxic encephalopathy. The clinical manifestation and electrophysiologic study support the clinical diagnosis of intermediate syndrome. The syndrome carries a risk of death. because of respiratory paralysis, if not recognized early and treated adequatedly. Prompt endotrachial intubation and mechanical ventilatory support is the cornerstone of treatment of the intermediate syndrome. Therefore, all patient should be observed in a hospital for up to 5 days after poisoning.

급성 유기인제 중독에서의 주사망 원인인 호흡부전은 급성 콜린성 위기시에 발생하지만 콜린성 위기에서 회복된 후 콜린양 증상의 동반없이 24-96시간에 근위부 사지근육, 경부굴근 및 운동뇌신경 분포근육의 무력증과 함께 호흡부전이 발생하기도 한다. 이를 IMS이라 하며 조기에 인지하고 적절히 치료하지 못했을 때 호흡근 마비로 사망 할 수 있어 모든 유기인제 중독환자를 최소 5일 이상 병원내에서 무호흡보조 치료에 대한 준비상태를 갖추고 근접관찰 하여야 한다. 저자들은 유기인제 중독에서 콜린성 위기 회복후 호흡부전을 유발한 IMS 2 례를 경험하였기에 문헌고찰과 함께 보고하는 바이다.