Selected Topics: Toxicology
Transient Cardiac Effects in a Child with Acute Cholinergic Syndrome Due to Rivastigmine Poisoning

https://doi.org/10.1016/j.jemermed.2013.11.078Get rights and content

Abstract

Background

We report a case of rivastigmine poisoning resulting in a full cholinergic syndrome with nicotinic, muscarinic, and central effects requiring supportive or intensive care in a pediatric patient.

Case Report

A 3-year-old girl was admitted to the Emergency Department suspected of having ingested one or two pills of rivastigmine. The child was hyporeactive, with symptoms of altered mental status, sialorrhea, sweating, and diarrhea. Subsequently, she started showing signs of respiratory failure, severe tracheobronchial involvement, and gastric and abdominal distension. An electrocardiogram recorded frequent monomorphic ventricular ectopic beats with bigeminy and trigeminy. Long-term follow-up showed a transient dysrhythmia.

Conclusion

Poisoning with rivastigmine can be a life-threatening condition. Timely identification and appropriate management of the toxic effects of this drug are essential and often life-saving. This is particularly true in cases of cholinergic syndrome subsequent to drug poisoning. Patients with cholinergic syndrome should also be assessed for possible cardiac complications such as dysrhythmias. The main factors predisposing to the development of such complications are autonomic disorder, hypoxemia, acidosis, and electrolyte imbalance.

Introduction

Rivastigmine is one of the three cholinesterase inhibitors, the others being donepezil and galantamine, currently indicated for the treatment of cognitive symptoms in probable Alzheimer's disease (1). Estimated cases of dementia are currently over 35.6 million, though this number is expected to increase, doubling every 20 years, so as to reach 115.4 million people in 2050 (2). It is estimated that 1 in 10 patients with dementia in Europe is treated with cholinesterase inhibitors (3).

Rivastigmine is a noncompetitive, reversible, acetylcholinesterase inhibitor (1). Some cases of poisoning or toxicity due to overdose with rivastigmine are described in adults 4, 5, 6, 7. To our knowledge, only one case of poisoning with rivastigmine has been reported in a child: an 11-month-old girl who accidentally chewed a rivastigmine capsule and showed only nicotinic effects (hypotonia, hyporeflexia, miosis, and weak cry) (8).

We report the second pediatric case of poisoning subsequent to the accidental ingestion of rivastigmine. Our patient is the first reported case with full cholinergic syndrome (ChoS), including respiratory failure and transient cardiac complications, which resulted in a favorable outcome.

Section snippets

Case Report

A 3-year-old, otherwise healthy, Italian girl was admitted to the local Emergency Department (ED) 45 min after a suspected ingestion of rivastigmine. The child was conceived by healthy, nonconsanguineous parents and delivered uneventfully by natural childbirth. She was not taking any medication prior to admission, and had normal psychomotor development. Rivastigmine had been prescribed to her paternal grandfather for the treatment of Alzheimer's disease. The child ingested one or two of these

Discussion

Rivastigmine is a centrally acting, pseudo-irreversible, selective acetylcholinesterase and butyrylcholinesterase inhibitor used for the treatment of Alzheimer's disease (9). Reports have also been published about its off-label use in children with autism spectrum disorders and Down syndrome 10, 11, 12. Our patient is, to our knowledge, the second reported pediatric case of rivastigmine poisoning with a subsequent ChoS similar to the syndrome caused by organophosphate poisoning (Table 1). The

Conclusions

Emergency physicians facing a patient presenting with a short and temporary organophosphate-like toxidrome should consider poisoning with cholinesterase inhibitors such as donepezil, rivastigmine, galantamine, and tacrine (5). The ingestion of rivastigmine in pediatric patients can be a life-threatening condition. A delay in diagnosis or improper management can lead to death. Early diagnosis and appropriate treatment are therefore crucial, as they can be life saving, particularly in case of

References (24)

  • M.W. Lai et al.

    Pesticide-like poisoning from a prescription drug

    N Engl J Med

    (2005)
  • J. Birks et al.

    Rivastigmine for Alzheimer's disease

    Cochrane Database Syst Rev

    (2009)
  • Cited by (3)

    • Characteristics of pediatric exposures to antidementia drugs reported to a poison control system

      2016, Journal of Pediatrics
      Citation Excerpt :

      Reports of pediatric toxicity from rivastigmine exposures are limited to 2 case reports in the medical literature. One describes a 3-year-old girl who developed altered mental status and dysrhythmias after ingesting between 4.5 and 9 mg of rivastigmine.13 She was treated with atropine and recovered fully.

    View full text