title: Recurrent tonic-clonic seizures and coma due to ingestion of Type I pyrethroids in a 19-month-old patient.
abstract: BACKGROUND
  Pyrethroids are synthetic pyrethrin analogues that induce sodium-channel depolarization and hyperexcitation. Severe pyrethroid poisoning is manifested by a "Tremor Syndrome" (Type I cyano-agents) or a "Choreoathetosis/Salivation Syndrome" (Type II non cyano-agents). Very few reports of neurotoxic effects caused by Type I pyrethroids ingestion are available, and no human data concerning Type I pyrethroid blood levels in pediatric poisoning are reported in the medical literature.
  
  
  METHODS
  A 19-month-old female patient presented with irritability and inconsolable crying that rapidly worsened to tonic-clonic seizures and coma (GCS 6). On admission vital signs including BP 110/70 mmHg, HR 110 beats/min, and SpO2 98% on room air were normal. Orotracheal intubation, oxygen administration, and midazolam infusion (4 μg/kg/min) were performed. Intravenous thiopental sodium, up to 18 mg/kg/hour, was administered to control convulsions. An inquiry revealed that 9 h before presentation the patient had ingested an unknown amount of an insecticide containing 7% piperonyl-butoxide and a mixture of the Type I pyrethroids bifenthrin (5%) and esbiothrin (3%). Consequently, gastric lavage was performed, followed by administration of activated charcoal and cathartics. On the subsequent 48 h, the patient returned progressively alert; she was extubated on day 4 and discharged asymptomatically 12 days after hospitalization. After 9, 48, and 72 h of ingestion, the plasma levels were 500, 95, and 40 ng/mL for bifenthrin and 1,640, 640, and 165 ng/mL for piperonyl-butoxide respectively.
  
  
  CONCLUSIONS
  This pediatric case showed severe pyrethroid neurotoxicity associated with measurable plasma levels of bifenthrin and piperonyl-butoxide. In pediatric pyrethroid poisoning, coma and seizures may represent the main life-threatening features. First-aid therapy including airway maintenance and control of muscle fasciculation and seizures is of major importance. Benzodiazepines and high-dose thiopental sodium were effective treatments for convulsion.
authors.affiliation: IRCCS Maugeri Foundation Clinical Institute and University of Pavia, Pavia Poison Centre and National Toxicology Information Centre, Pavia, Italy. andrea.giampreti@unipv.it
authors.forename: A
authors.initials: A
authors.lastname: Giampreti
authors.forename: L
authors.initials: L
authors.lastname: Lampati
authors.forename: G
authors.initials: G
authors.lastname: Chidini
authors.forename: L
authors.initials: L
authors.lastname: Rocchi
authors.forename: L
authors.initials: L
authors.lastname: Rolandi
authors.forename: D
authors.initials: D
authors.lastname: Lonati
authors.forename: V M
authors.initials: VM
authors.lastname: Petrolini
authors.forename: S
authors.initials: S
authors.lastname: Vecchio
authors.forename: C A
authors.initials: CA
authors.lastname: Locatelli
authors.forename: L
authors.initials: L
authors.lastname: Manzo
mesh_terms: D000487:Allethrins / Q000031:analogs & derivatives / Q000097:blood / Q000633:toxicity; D003128:Coma / Q000139:chemically induced*; D004830:Epilepsy, Tonic-Clonic / Q000139:chemically induced*; D005260:Female; D008401:Gas Chromatography-Mass Spectrometry; D006801:Humans; D007223:Infant; D007306:Insecticides / Q000097:blood / Q000633:toxicity*; D011722:Pyrethrins / Q000097:blood / Q000633:toxicity*
chemical_list: D000487:Allethrins; D007306:Insecticides; D011722:Pyrethrins; C099952:bifenthrin; C054159:esbiothrin