Chronic organophosphate-induced neuropsychiatric disorder: a case report

Neuropsychiatric Disease and Treatment Dovepress open access to scientific and medical research C a s e r e p o rt Neuropsychiatric Disease and Treatment downloaded from https://www.dovepress.com/ by 37.59.46.207 on 12-Jul-2018 For personal use only. Open Access Full Text Article Chronic organophosphate-induced neuropsychiatric disorder: a case report This article was published in the following Dove Press journal: Neuropsychiatric Disease and Treatment 4 February 2016 Number of times this article has been viewed Shree Ram Ghimire 1 Sarita Parajuli 2 Department of Psychiatry, National Medical College, Birgunj, 2Department of Anesthesiology, Kathmandu National Medical College, Anamnagar, Kathmandu, Nepal 1 Abstract: Chronic organophosphate (OP)-induced neuropsychiatric disorder is a rare condition following prolonged exposure to OP compounds. Due to the lack of valid diagnostic tools and criteria, very few cases are seen in clinical practice and are often misdiagnosed. Misdiagnosis can lead to inappropriate treatment that may increase the risk of morbidity or suicidality. In this paper, we present the case of a 35-year-old male who needed support in breathing from a mechanical ventilator and developed neuropsychiatric behavioral problems following ingestion of OP compounds, which lead to suicidality. The patient was treated by the psychiatric team with antipsychotic and antidepressants and improved following the regular use of medication. Keywords: COPIND, mood liability, suicidal thoughts Introduction As a country where agriculture is predominant, Nepal uses a lot of organophosphate (OP) pesticides as they are commonly available. OP pesticide poisoning is a leading cause of morbidity and premature loss of life in many developing countries, including Nepal.1 Chronic OP-induced neuropsychiatric disorder (COPIND) is a condition characterized by a prolonged exposure to OP pesticides (with or without acute cholinergic episodes) and the development of various neuropsychiatric symptoms.2 Follow-up studies of individuals who were exposed to high levels of the OP compound have shown an emergence of certain similar types of neurobehavioral changes, which has been termed together as COPIND.3 The neurobehavioral changes include anxiety, mood swings, emotional lability, depression, fatigue, irritability, drowsiness, confusion, and lethargy.4 The purpose of this case study is to determine the neuropsychiatric manifestation of prolonged exposure to OP compounds. As few cases of this kind have been reported or seen in practice, this report may help others in understanding and diagnosing COPIND. Case report Correspondence: Shree Ram Ghimire Department of Psychiatry, National Medical College, PO Box 78, Birgunj, Parsa 44400, Nepal Email 275 submit your manuscript | www.dovepress.com Neuropsychiatric Disease and Treatment 2016:12 275–277 Dovepress © 2016 Ghimire and Parajuli. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). http://dx.doi.org/10.2147/NDT.S91673 Powered by TCPDF (www.tcpdf.org) In an attempted suicide after quarreling with his wife, a 35-year-old male farmer from the plain (Terai) region of Nepal poisoned himself with OP pesticide (malathion). He had been using OP as a pesticide in his field, as per the advice of an agriculture technician, for over a week at the time of the incident. The unconscious farmer was taken to a nearby hospital in India, near the border, where he suffered from vomiting, salivation, and diarrhea. After being on a mechanical ventilator for 9 days, he was brought to the National Medical College and Teaching Hospital, Birgunj, Nepal. The patients’ record showed that his symptoms included deep coma (Glasgow Coma Scale E1V1M1), hypotension (80/56 mmHg), tachycardia (128/min), miosis, and Dovepress Neuropsychiatric Disease and Treatment downloaded from https://www.dovepress.com/ by 37.59.46.207 on 12-Jul-2018 For personal use only. Ghimire and Parajuli hypersalivations. The patient was administered activated charcoal and was continuously infused with atropine sulfate. His plasma cholinesterase value was not tested due to the lack of access to the test. After being brought to the National Medical College and Teaching Hospital, the patient was kept in the intensive care unit under breathing support with a mechanical ventilation and under 24 hours vigilance. His consciousness and respiratory status gradually improved, and he was taken off the mechanical ventilator on the 12th day of his admission. After this time, he developed irritability, restlessness, nonsensical talking, and psychosis. The neurological examination revealed resting and postural tremors, and marked cogwheel rigidity. An examination of his mental status revealed uncooperativeness, irritability, abnormal behavior, decreased volume and pitch of speech, increased reaction time, labiality of mood, impaired attention and concentration, and disorientation to time, place, and person. The diagnosis of delirium was made along with a suspicion of Parkinsonism. The antipsychotic drug, quetiapine, was started at a low dose of 25 mg once daily, and then was gradually increased over 3 days to 50 mg, which showed dramatic improvements within 2 days. By the 18th day of admission, a decision was made to transfer the patient to the Psychiatry Inpatient Department for further management of his psychiatric manifestation, where he was continued on with the same medications. Consistent mood liability, irritability, fatigability, and features of anxiety were observed; however, features of Parkinsonism were seen to be improving. Through a detailed history from his spouse, friends, and other family members, major medical, surgical, and psychiatric illness, and substance abuse were all ruled out. The patient consumed alcohol occasionally, but did not portray patterns of dependency. In addition, the detailed history explored the attempted suicide and saw it as an impulsive act rather than one motivated by depression. The patients’ medical history showed mood swings along with suicidal thoughts were persistent. An antidepressant, fluoxetine 20 mg, was started once daily and suicidal precaution was explained to family members. Upon persistent requests from the family, the patient was discharged with the same medication and advised to return for a 2-week follow-up at the Psychiatry Outpatient Department. Gradual improvement in hi (...truncated)