Organophosphorus Compound Induced 'Intermediate Syndrome'

Organophosphate compound (OPC) poisoning with suicidal intent is common in Indian ICUs. These compounds are the organic derivatives of phosphorous containing acids and their effect on neuromuscular junction and autonomic synapses is clinically important. Organophosphate poisoning can present as acute cholinergic syndrome, intermediate syndrome and delayed neuropathy. Intermediate syndrome secondary to organophosphate poisoning is a serious health problem leading to increased morbidity and mortality. The incidence of problem varies and ranges from 8%-84% of OPC poisoning cases. After initial recovery from cholinergic crisis, some patients have resurgence of respiratory muscle paralysis requiring continued ventilatory support. This is termed intermediate syndrome (IMS). The factors accounting for this difference is the nature of organophosphate compound, severity of poisoning and inadequate oxime therapy. The recognition of this syndrome is important as if this entity is overlooked it can have disastrous effects. Our patient had developed respiratory muscle weakness as evidenced by inadequate respiratory efforts, drop in oxygen saturation, retention of CO2 and need for ventilatory support. There was no evidence of weakness in ocular, neck, bulbar muscles but he had weakness in all 4 limbs more pronounced in proximal muscles. We presented this case of OPC poisoning with intermediate syndrome, which remained for a prolonged time and required mechanical ventilation for 16 days. This case highlights how the timely intervention can save the patient’s life.