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Poisoning with Rivastigmine

CASE REPORT A 59-year-old man with a noncontributory medical history was found comatose and soiled after having urinated and defecated while unconscious. During transport to the Emergency Department (ED) he had two seizures that resolved spontaneously. On arrival, he was somnolent and he vomited. He had miosis, nystagmus, and excessive salivary and bronchial secretions. Breathing was shallow at a respiratory rate of 28 per minute between apneic pauses. Diffuse crackles were heard in his lungs. His tympanic temperature was 33.5 C, pulse 79 beats per minute, supine blood pressure 180/ 90 mmHg, and SpO2 76% on room air. The patient was intubated, suctioned, and ventilated. Atropine 3 mg intravenously cleared the bronchial secretions. Gastric lavage was performed and activated charcoal was given 1 hour after presentation. Gastric content had a normal smell. His initial laboratory test results were serum sodium 135 mmol/L, potassium 3.0 mmol/L, BUN 4.5 mmol/L, creatinine 65 mmol/L, glucose 12.9 mmol/L, and bicarbonate 26 mmol/L. Plasma butyrylcholinesterase was 6.0 mkat/L (normal 60–190 mkat/L). An electrocardiogram showed a sinus tachycardia and a brain CT scan revealed no pathological changes. Between 5 and 13 hours after presentation he had three periods of bradycardia (30 beats per minute), which were reversed with atropine 1 mg each time. Artificial ventilation was stopped 23 hours after presentation and he was extubated 3 hours later. After extubation his physical examination was unremarkable, lungs were clear, and cholinergic signs were absent. He reported that he had taken 48 tablets of Exelon (288 mg of rivastigmine) and 28 tablets of Cipramil (280 mg of citalopram) in a suicide attempt 5 hours before he was found. The drugs belonged to his mother who has Alzheimer’s disease. A toxicological screening of gastric content by gas chromatography–mass spectrometry (incapable of detecting rivastigmine) was positive only for citalopram. During the rest of his hospitalization he felt dizziness and fatigue, but his physical examination was otherwise unremarkable. Plasma butyrylcholinesterase gradually returned to normal values in 5 days (Fig. 1). Red blood cell acetylcholinesterase was not measured. The patient was discharged after psychiatric evaluation on the fifth day.