Alexandria Poison Center Case Report of Acute Poisoning Following Intramuscular Injection of Cholinesterase Inhibitor Insecticide and the Possible Role of L-Carnitine in Management

Background: Cholinesterase inhibitor (ChEI) insecticide is a common cause of poisoning in developing countries. Toxicity occurs by ingestion, inhalation, or dermal absorption. However, only a few cases of parenteral poisoning have been reported, so far. The inhibition of cholinesterase itself is not enough to explain the wide range of disorders associated with ChEIs insecticide exposure. Oxidative stress is supposed to be a contributing factor to the complications of ChEIs insecticide poisoning. L-carnitine (LC) is a widely accessible antioxidant therapy that is a safe drug with fewer side effects and it could be considered as a promising adjuvant treatment in acute ChEIs insecticide poisoning. Case Presentation: The current case report describes a 60-year-old male with a homicidal intramuscular injection of ChEI insecticide, presented with chest crepitations and fasciculations. He showed an initial improvement to treatment with atropine, toxogonin, and L-carnitine (LC) and discharged. However, there was an aggressive reaplse of symptoms after five days necessitating readmission and mechanical ventilation. After two weeks of treatment with the same regimens, the patient s condition improved significantly and he was discharged with complete recovery. Conclusion: The diagnosis of ChEI toxicity by the parenteral route is a challenge, where the onset of symptoms may be delayed with atypical presentations. Even though the symptoms are mild initially, observation for a more extended period is mandatory. LC could be a promising adjuvant antioxidant treatment in acute ChEIs insecticide poisoning case.