Selected Topics: ToxicologyTransient Cardiac Effects in a Child with Acute Cholinergic Syndrome Due to Rivastigmine Poisoning
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.
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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
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Cited by (3)
Availability in Spain of “one pill killers” and other highly toxic drugs in infants
2020, Anales de PediatriaCharacteristics of pediatric exposures to antidementia drugs reported to a poison control system
2016, Journal of PediatricsCitation 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.
The first use of pralidoxime in a child with rivastigmine poisoning
2018, Pediatric Emergency Care