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Atypical manifestations of organophosphorus poisoning following subcutaneous injection of Dichlorvos with suicidal intention.
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PMID:  24872656     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Current case report describes a 37-year-old female patient who was admitted to the hospital following subcutaneous injection of Dichlorvos with an insulin syringe. The only peripheral cholinergic sign observed on admission was excessive salivation with bilateral pyramidal tract signs. Locally she had necrosis of skin and subcutaneous tissue with surrounding blisters. In the subsequent course of her illness, she developed respiratory arrest requiring ventilator support. She also had delayed extrapyramidal manifestations. Relevant literature is reviewed. Possibility of route-specific, delayed predominant central nervous system effect of Dichlorvos postulated.
Supradip Ghosh
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine     Volume:  18     ISSN:  0972-5229     ISO Abbreviation:  Indian J Crit Care Med     Publication Date:  2014 Apr 
Date Detail:
Created Date:  2014-05-29     Completed Date:  2014-05-29     Revised Date:  2014-06-02    
Medline Journal Info:
Nlm Unique ID:  101208863     Medline TA:  Indian J Crit Care Med     Country:  India    
Other Details:
Languages:  eng     Pagination:  244-6     Citation Subset:  -    
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Journal Information
Journal ID (nlm-ta): Indian J Crit Care Med
Journal ID (iso-abbrev): Indian J Crit Care Med
Journal ID (publisher-id): IJCCM
ISSN: 0972-5229
ISSN: 1998-359X
Publisher: Medknow Publications & Media Pvt Ltd, India
Article Information
Copyright: © Indian Journal of Critical Care Medicine
Print publication date: Month: 4 Year: 2014
Volume: 18 Issue: 4
First Page: 244 Last Page: 246
PubMed Id: 24872656
ID: 4033860
Publisher Id: IJCCM-18-244
DOI: 10.4103/0972-5229.130578

Atypical manifestations of organophosphorus poisoning following subcutaneous injection of Dichlorvos with suicidal intention
Supradip Ghoshaff1
From: Department of Critical Care Medicine, Fortis-Escorts Hospital, NIT, Faridabad, Haryana, India
Correspondence: Correspondence: Dr. Supradip Ghosh, Department of Critical Care Medicine, Fortis-Escorts Hospital, Neelam Bata Road, NIT, Faridabad - 121 001, Haryana, India. E-mail:


Dichlorvos (dimethyl-2, 2-dichloro vinyl phosphate) is an organophosphorous (OP) insecticide with moderate human toxicity, used for insect control in food storage areas, greenhouses, barns and control of insects on livestock. Parenteral Dichlorvos administration with suicidal intention is rarely reported in the literature. In one case report, extensive muscle necrosis was reported following intramuscular injection of Dichlorvos.[1] In another case, following injection of Dichlorvos subcutaneously in both wrists, a young patient developed compartment syndrome requiring fasciotomy.[2] In both cases authors did not observe any evidence of systemic toxicity. In the following report, I describe the case of a young female patient, who developed atypical signs of OP poisoning following subcutaneous injection of Dichlorvos.

Case Report

The present case report is about a 37-year-old, previously healthy female, who was admitted to our intensive care unit 18-h after alleged self-injection of 76% Dichlorvos (NUVOS) 3 ml in the upper left arm (3 times with a 1 ml Insulin syringe). Within an hour of the injections, she developed local pain and swelling. 8-10 h later she noticed excessive salivation. On examination, she had normal body temperature with heart rate of 90/min, blood pressure 110/70 mmHg, respiratory rate 14/min and pulse oximeter showing 100% saturation on room air. She had bruxism and bubbling of saliva from the mouth. Her pupils were bilateral 2 mm, reacting to light. No crackles were heard on chest auscultation. On the nervous system examination, she was jittery with slurred speech and normal cranial nerves. She had hypertonia, brisk tendon reflexes, bilateral sustained ankle clonus and bilateral extensor plantar reflex. Local examination revealed a blister and a black necrotizing lesion over the anterior aspect of the left arm [Figure 1]. Blood gas analysis showed normal values. She was rapidly atropinized with incremental boluses of atropine (total dose 12 mg) in next 30 min (targeting a dry mouth) followed by infusion of 1.8 mg/h. Pralidoxime infusion was started at 500 mg/h following a loading dose of 1000 mg over 20 min. Intravenous Clindamycin (600 mg q 8 h) was administered empirically for presumed local wound infection. Debridement of the wound showed predominant involvement of the subcutaneous tissue plane with minimal necrosis of the superficial fibers of biceps brachii. Initial routine laboratory investigations were unremarkable except elevated total count (16200/mm3) and mild respiratory alkalosis.

Her clinical course was complicated by respiratory arrest 9-h after hospital admission (27-h after the injection of Dichlorovos) leading to hypoxia and bradycardia. Arterial blood gas analysis post resuscitation showed-pH 7.28, PO2-36 mmHg, PCO2-54 mmHg, HCO3-22 mmHg. She was intubated and started on mechanical ventilation. Serum choline esterase (pseudo cholinesterase) level of the same day showed a very low value of <1 kU/L (normal range 3.93-10.8 kU/L). Subsequent 3 days course were unremarkable. She could be successfully weaned off from the ventilator on day 4.

On day 5, while on atropine infusion she was found to be delirious. She was also noticed to have extrapyramidal manifestations including rigidity and left sided gaze preference. Atropine infusion was stopped. In subsequent days, she showed gradual improvement in her neurological status. Extrapyramidal manifestations lasted for 3 days. Pralidoxime infusion was continued empirically for total 7 days. She and was finally discharged from the hospital on day 10.


In this case, other than the unusual route of administration, a number of atypical manifestations were found. This includes relatively delayed respiratory failure and central nervous system (CNS) manifestations with few muscarinic signs.

Two independent mechanisms are thought to be responsible for respiratory failure following OP insecticide poisoning – cholinergic CNS depression in the early stage (associated with other cholinergic features) and late progressive neuromuscular transmission defect.[3] Second mechanism is part of the syndrome described as “Type II paralysis” by Wadia et al. or intermediate syndrome by Senanayake and Karalliedde.[4, 5] Our patient developed respiratory arrest 27-h after exposure to Dichlorovos. At that time she was conscious and adequately atropinized without any peripheral muscarinic sign. In her clinical course she never had neck or proximal muscle weakness, though the clinical findings were not correlated electrophysiologically.

Hyperactivation of cholinergic neurons is responsible for the CNS manifestations of OP insecticides.[6] Usually CNS signs are manifested early in the course in the presence of peripheral muscarinic signs. In a large series published on neurological manifestations of OP compounds, 8 of 200 patients had pyramidal tract signs in the form of only hyper-reflexia manifesting within 24 h of exposure.[4] All these patients were unconscious with florid cholinergic manifestations, including constricted pupils.[4] In their original series of intermediate syndrome Senanayake and Karalliedde, observed hyperreflexia in one of their patients (with flexor plantar reflex) and even she had typical muscarinic signs.[5] Extrapyramidal signs of OP poisoning are often transient and may be missed in a sick patient. In a Taiwanese series extrapyramidal signs were noticed within 4 days of intoxication.[7] In our patient, CNS manifestations (both pyramidal tract and extrapyramidal) were delayed and were associated with relatively scanty peripheral muscarinic signs.

Possible explanation for these atypical manifestations in our patient could be route specific (in this case subcutaneous) effect of OP compound (Dichlorovos) causing isolated delayed CNS depression, with few peripheral cholinergic signs. Animal experiments have shown route specific (subcutaneous or intravenous) cardiovascular and neuromuscular effect of OP compounds in rats.[8] This hypothesis may be tested by further experiments on large animals.


Source of Support: Nil

Conflict of Interest: None declared.


I sincerely acknowledge the contributions of my colleagues from the Departments of Critical Care Medicine and staff of the Intensive Care Unit, Fortis-Escorts Hospital, Faridabad for their contributions in the clinical management of the patient. I also acknowledge the contribution of my wife Dr. Sonali Ghosh for her constructive input and reviewing of the manuscript.

1. Güloglu C,Aldemir M,Orak M,Kara IH. Dichlorvos poisoning after intramuscular injectionAm J Emerg MedYear: 2004223283015258888
2. Yucel I,Demiraran Y,Alper M. Suicide attempt with injection of insecticide in both wristsOrthopedicsYear: 20083117419292194
3. Jayawardane P,Senanayake N,Buckley NA,Dawson AH. Electrophysiological correlates of respiratory failure in acute organophosphate poisoning: Evidence for differential roles of muscarinic and nicotinic stimulationClin Toxicol (Phila)Year: 201250250322455356
4. Wadia RS,Sadagopan C,Amin RB,Sardesai HV. Neurological manifestations of organophosphorous insecticide poisoningJ Neurol Neurosurg PsychiatryYear: 19743784174853328
5. Senanayake N,Karalliedde L. Neurotoxic effects of organophosphorus insecticides. An intermediate syndromeN Engl J MedYear: 198731676133029588
6. Chen Y. Organophosphate-induced brain damage: Mechanisms, neuropsychiatric and neurological consequences, and potential therapeutic strategiesNeurotoxicologyYear: 20123339140022498093
7. Hsieh BH,Deng JF,Ger J,Tsai WJ. Acetylcholinesterase inhibition and the extrapyramidal syndrome: A review of the neurotoxicity of organophosphateNeurotoxicologyYear: 200122423711577800
8. Dube SN,Kumar P,Kumar D,Das Gupta S. Route-specific cardiorespiratory and neuromuscular changes following organophosphorous poisoning in ratsArch Int Pharmacodyn TherYear: 1993321112228323413


[Figure ID: F1]
Figure 1 

Local skin necrosis with surrounding blisters

Article Categories:
  • Case Report

Keywords: Central nervous system manifestations, respiratory arrest, subcutaneous dichlorvos.

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