The use of glycopyrrolate in a case of intermediate syndrome following acute organophosphate poisoningPurpose: This report describes a case of organophosphate intoxication refractory to atropine in which glycopyrrolate was used to reduce cholinergic symptoms, and describes the development of intermediate syndrome, an uncommon subacute complication of organophosphate poisoning. Clinical features: A 44-yr-old woman presented in cholinergic crisis following malathion ingestion. Treatment was initiated with atropine and pralidoxime. Despite clinical signs of adequate atropinisation, the patient continued to have profuse bronchorrhoea, which resolved with glycopyrrolate. During her course in the intensive care unit, she displayed a subacute deterioration in neuromuscular and mental status with decrement-increment phenomenon on electromyography consistent with intermediate syndrome. The patient eventually made a complete recovery. Conclusion: This case report describes the successful use of glycopyrrolate in organophosphate intoxication and the development of the intermediate syndrome, characterised by onset of weakness of neck flexors, proximal limb muscles, and respiratory muscles within one to four clays after poisoning. Recognition of the syndrome is important in light of the potential for respiratory depression requiring ventilatory support.Objectif : Cette observation d&rit un cas d'intoxication aux organophosphor& r6fractaire ~ ratropine o6 le glycopyrrolate a ~t~ utilis~ pour diminuer les sympt6mes cholinengiques, et d&rit aussi le d~veloppement d'un syndrome interm~diaire, une complication subaigu~ non fr~quente de I'empoisonnement aux organophosphor~s. l~,l~ments cliniques : Une femme de 44 ans se pr&ente en crise cholinergique suite ~ I'ingestion de malathion. On d~bute le traitement ~. ratropine et ~ la pralidoxime. Malgr~ des signes cliniques d'atropinisation adequate, la patiente continue ~ pr&enter une bronchorrh~e profuse, qui rentre dans I'ordre avec le glycopyrrolate. Durant son s~jour aux soins intensifs, elle pr&ente une d&&ioration subaigua de la fonction neuromusculaire et mentale avec ph~nom~ne incr~mentiel-d&r~mentiel ~ I'~lectromyographie, compatible avec un syndrome interm~-diaire. Cette patiente va &entuellement r&up&er compl&ement. Conclusion : Cette observation ~ propos d'un cas d&rit I'utilisation avec succ& du g!ycopyrrolate dans I'intoxication aux organophosphor& et la survenue d'un syndrome interm~diaire caract&is~ par rapparition de faiblesse au niveau des fl&hisseurs du cou, des muscles proximaux des membres et des muscles respiratoires survenant dans un d~lai de un ~ quatre jours apr& I'intoxication. Lidentification de ce syndrome est importante ~ cause de son potentiel d'insuffisance respiratoire n&essitant un support ventilatoire.
Unilateral absence of the pulmonary artery (UAPA) represents a rare condition that is often associated with cardiac congenital abnormalities but can also be relatively asymptomatic and indolent. There is a lack of consensus regarding the management of UAPA. However, in the setting of associated complications and ongoing infection, pulmonary resection is advocated. Although rare, the association between UAPA and bronchogenic carcinoma has been previously reported in seven published cases. In the majority of these, anatomic lung resection (most commonly with pneumonectomy) was curative. We present the first reported case of ipsilateral metastatic non-small-cell lung cancer- (NSCLC-) associated UAPA in a 47-year-old patient with ventilator-dependent hypoxic respiratory failure and bronchorrhea, who had been lost to follow-up for 8 years. Initial investigations did not yield evidence of malignancy, and confirmation of metastatic disease was made intraoperatively at the time of thoracotomy. The findings demonstrated evidence of diffuse metastatic pleural disease with lymphangitic carcinomatosis and superimposed infection. The patient was palliated and passed away shortly thereafter. In the setting of UAPA, clinicians should have a high index of suspicion for the possibility of malignancy, and if proven, they should consider early resection following appropriate staging.
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