• Toshiki Sera, Shinji Kusunoki, and Nobuaki Shime.
• Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Minami-ku, Hiroshima, Japan.
• Medicine (Baltimore). 2022 Nov 25; 101 (47): e31677e31677.

RationaleDistigmine bromide is a cholinesterase (ChE) inhibitor used to treat dysuria due to a hypotonic bladder. We encountered a case of cholinergic crisis caused by distigmine bromide, which resulted in a rapid decrease in serum ChE levels, hypothermia, respiratory failure, and circulatory failure within a short period of time.Patient ConcernsA 51-year-old man was admitted to a psychiatric hospital to treat behavioral disorders due to irritability and violent behavior. The patient was referred to our hospital for septic shock secondary to urinary tract infection and respiratory failure. He had not defecated for 5 days before visiting our hospital. He had moderate intellectual disability. Immediately after admission, he developed hand tremors and drooling. The airway was obstructed by drooling due to vomiting of yellow clear gastric juice.DiagnosisThe patient's high saliva volume, bradycardia, respiratory failure (54 breaths/min), constricted pupils (2.5/mm), poor oxygenation, and a history of oral medication were consistent with the diagnosis of cholinergic crisis due to distigmine bromide.InterventionsOn admission, the patient was immediately intubated. He was treated with noradrenaline (0.1 µg/kg/min) to increase his blood pressure. He was admitted to the intensive care unit (ICU). Since he had circulatory failure, vasopressin (approximately 1 U/h) was administered. Continuous intravenous atropine sulfate (0.6 mg/h) was also administered for high saliva volume.OutcomesOn the 8th ICU day, the patient's drooling and bradycardia improved. The patient was physically and mentally stable, and transferred to the referring hospital.LessonsChE levels and symptoms before onset may not be useful for the early detection and prevention of adverse effects of cholinergic crisis caused by distigmine bromide. In addition to known risks such as renal impairment and older age, constipation should be recognized and communicated as a risk factor.Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.

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