Özgür KARCIOĞLU, NEŞE ÇOLAK ORAY, Hakan TOPAÇOĞLU, Pınar ÜNVERİR

Akut miyokard infarktüsünün eşlik ettiği organofosfat zehirlenmesi

Amaç: Akut organofosfat (OP) zehirlenmesi üzerine çok fazla sayıda araştırma bulunmakla birlikte, OP maruziyeti sonrasında kardiyak enzim, klinik ve elektrokardiyografi (EKG) bulgularıyla birlikte ortaya çıkan bir akut miyokard infarktüsü (AMI) olgusu ilk kez bildirilmektedir. Olgu sunumu: Bilinen koroner arter hastalığı olmayan 57 yaşında kadın hasta evinde toz haldeki tarım ilacını per os intihar amaçlı almış. Evde yakınları tarafından baygın bulunup önce başka bir hastaneye götürülmüş ve genel durumu kötü olan hasta entübe edilmiş, ardından merkezimize transfer edilmiş. Hastanın acil serviste izleminde çekilen ilk EKG’sinde sinüs taşikardisi saptandı. İlk kardiyak enzimleri normal bulundu. İzlem EKG'lerinde değişik derivasyonlarda T negatifliği veya ST yükselmesi gelişti ve kardiyak enzimleri yüksek saptandı. Bu bulgularla hastada OP zehirlenmesine bağlı ST yükselmeli AMI düşünüldü. Zehirlenme ve AMI tedavisi sonrası yoğun bakımda ve serviste klinik bulguları tamamen düzelen hasta komplikasyonsuz taburcu edildi. Sonuç: OP zehirlenmesi ile başvuran hastalarda zehirlenmeye sekonder ortaya çıkan akut AMI gözardı edilmemelidir. Böyle bir şüphe durumunda EKG ve kardiyak enzim izlemi önerilir.

Anahtar Kelimeler:

Miyokard enfarktüsü, Fosforik asit esterleri, Orta yaşlı, Kadın, Zehirlenme

Organophosphate intoxication associated with acute myocardial infarction

Objective: Although many studies are available on acute organophosphate (OP) intoxication, this report represents the first published case suffering from acute myocardial infarction (AMI) documented with ECG, enzyme and clinical characteristics, following exposure to OP compounds. Case report: A woman aged 57 yrs with no documented disease other than depression has been found unconscious by relatives in her house after ingesting a pesticide compound. She was intubated in a community hospital before being transferred to the University-based emergency department (ED). The first ECG in the ED revealed only sinus tachycardia, along with normal cardiac enzymes. In the ED follow-up, however, ST segment elevation of 1 mm and negative T waves in various leads ensued. Cardiac enzymes were found abnormally elevated. These findings suggested acute ST-elevation AMI associated with OP intoxication which were treated accordingly. Aggressive treatment was followed by full recovery and the patient was discharged without any sequelae in two weeks. Conclusion: The physicians should kept in mind that the severely intoxicated patient with OP compounds could still harbor acute coronary syndromes complicating the picture. Close monitoring with ECG and cardiac enzymes is essential in the management.

Keywords:

Myocardial Infarction, Phosphoric Acid Esters, Middle Aged, Female, Poisoning,

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1. Potter WZ, Hollister LE. Cholinesterase inhibitors. İçinde: Katzung BG, editör. Basic and Clinical Pharmacology Lange, McGraw-Hill, 2004. p. 992-93. 2. Watson WA, Litovitz TL, Klein-Schwartz W, Rodgers GC Jr, Yovniss J, Reid N, et al. 2003 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 2004;22:335-403. 3. Robey WC, Meggs W: Insecticides, herbicides, rodenticides. İçinde: Tintinalli JE, editör. Emergency Medicine A Comprehensive Study Guide. 5th ed. New York, McGraw-Hill, 2000. p.1174-82. 4. Mokhlesi B, Leikin J.B, Murray P, Corbridge T.C. Organophosphates and carbamate insecticides. Adult Toxicology in critical care, Part II: Specific Poisonings Chest 2003;123:911-2. 5. Peter JV, Cherian AM. Organic insecticides. Anaesth Intensive Care 2000;28:11-21. 6. Karki P, Ansari JA, Bhandary S, Koirala S. Cardiac and electrocardiographical manifestations of acute organophosphate poisoning. Singapore Med J 2004;45:385-9. 7. Finkelstein Y, Kushnir A, Raikhlin-Eisenkraft B, Taitelman U. Antidotal therapy of severe acute organophosphate poisoning: A multihospital study. Neurotoxicol Teratol 1989;11:593-6. 8. Saadeh AM, Farsakh NA, al-Ali MK. Cardiac manifestations of acute carbamate and organophosphate poisoning. Heart 1997;77:461-4. 9. Wang MH, Tseng CD, Bair SY. Q-T interval prolongation and pleomorphic ventricular tachyarrhythmia ('Torsade de pointes') in organophosphate poisoning: report of a case. Hum Exp Toxicol 1998;17:587-90. 10. Slapper D. Toxicity, Organophosphate and Carbamate. Emergency Medicine Online Textbook. Available at: http:// www.emedicine.com/ 05.08.2004. 11. Brill DM, Maisel AS, Prabhu R. Polymorphic ventricular tachycardia and other complex arrhythmias in organophosphate insecticide poisoning. Electrocardiol 1984;17:97-102. 12. Abraham S, Oz N, Sahar R, Kadar T. QTc prolongation and cardiac lesions following acute organophosphate poisoning in rats. Proc West Pharmacol Soc 2001;44:185-6. 13. Okudera H. Clinical features on nerve gas terrorism in Matsumoto. Clin Neurosci 2002; 9:17-21. 14. Kara IH, Guloglu C, Karabulut A, Orak M. Sociodemographic, clinical, and laboratory features of cases of organic phosphorus intoxication who attended the Emergency Department in the Southeast Anatolian Region of Turkey. Environ Res 2002; 88:82-8. 15. Cavaliere MJ, Calore EE, Perez NM, Puga FR. Organophosphate-induced myotoxicity. Rev Saude Publica 1996;30:267-72. 16. Povoa R, Cardoso SH, Luna Filho B, Ferreira Filho C, Ferreira M, Ferreira C. Organophosphate poisoning and myocardial necrosis. Arq Bras Cardiol 1997;68:377-80. 17. Ozyurt G, Yilmazlar A, Tamgac F, Kaplan N. The myocardium and brain SPECT findings in organophosphate poisoning. Eur J Emerg Med 1997;4:29-31. 18. Guven M, Sungur M, Eser B, Sari I, Altuntas F. The effects of fresh frozen plasma on cholinesterase levels and outcomes in patients with organophosphate poisoning. J Toxicol Clin Toxicol 2004;42:617-23.