chorea may be the manifestation of a wide variety of degenerative , vascular , metabolic , or toxic disorders involving the central nervous system , in which dysfunction of the basal ganglia , particularly of the striatum , is generally assumed to be responsible . we report an index case of generalized chorea secondary to the ingestion of propiconazole toxin ( fungicide ) in a young female . in this case , the patient was a 35-year - old lady who was a known case of primary juvenile myoclonic epilepsy , on treatment with valproate ( 800 mg / day ) for 7 years . she was found in unconscious state at home by the family , who then took her to the emergency department of another facility . in view of prior history of epilepsy , three days later , due to persistent unresponsive neurological condition , she was referred to our tertiary care hospital for further management . at admission , her glasgow coma scale was e2m5v1 , with bilateral small - sized pupils ( 2 mm , reacting ) , heart rate of 64/min , blood pressure 90/60 mmhg on inotropic support with norepinephrine 2 g / kg / min and dopamine 8 g / kg / min . blood biochemistry and metabolic profile were normal with total leukocyte count-12,000/mm , rbs-85 mg / dl , blood and urine culture were sterile . electroencephalogram was done to rule out status epilepticus while the patient was on valproate ( blood level-80 ) and no sedatives . magnetic resonance imaging ( mri ) brain with contrast , and cytological and biochemical analysis of cerebrospinal fluid were normal . on day 3 of her illness when inotropes had been tapered , her heart rate was in the range of 5058/min . bradycardia ( even with inotropic support ) along with small - sized pupils raised the suspicion of intoxication . furthermore , relatives were redirected to look for any evidence of suspicious compound at home . cholinesterase levels were very low ( 134 ) along with an empty bottle of propiconazole toxin ( fungicide ) found at home , confirming the diagnosis of intoxication . however , on the 9 day of her illness , she developed irregular random flowing movements from one part of the body to another , suggesting generalized chorea [ video 1 ] . a detailed family history was not positive for any chorea / choreiform movements suggestive of inherited degenerative disorders . the patient was extensively evaluated for other acquired cause of chorea , but her hematological investigations including peripheral blood film , biochemical , thyroid function , serum valproate levels , and vasculitic workup were negative and repeat mri brain and computed tomography ct abdomen were also normal . she was treated with clonazepam ( 2 mg ) , tetrabenazine ( 75 mg ) , and risperidone ( 2 mg ) with partial improvement in chorea . our case depicts initial diagnostic dilemma , which is frequent problem in intoxication as history is often concealed . hence , insecticide poisonings are relatively a common occurrence with wide spectrum of neurological presentations which may affect the function of the central and peripheral nervous system . clinical manifestations vary greatly , and include movement disorders such as secondary parkinsonism and a wide range of hyperkinetic disorders and even delayed neuropathy . propiconazole is the triazole class of fungicide and is available as an emulsifiable concentrate ready - to - use liquid [ figure 1 ] . it is also known as dmi or demethylation - inhibiting fungicide , due to its binding with and inhibition of 14-alpha - demethylase enzyme . to the best of our knowledge , this is the index case of generalized chorea following intoxication with propiconazole ( fungicide ) . the probable mechanism may be excessive acetylcholine activity in the nigrostriatal system due to inactivation of acetylcholinesterase by propiconazole . within the nigrostriatal network , caudate nucleus and globus pallidus are particularly rich in cholinergic neurons causing less inhibition of pallidothalamic fibers and generalized choreiform movements . chemical structure of propiconazole ( c15h17cl2n3o2 ) the neurological manifestation with propiconazole intoxication is not reported in literature . only few cases of extrapyramidal manifestations following cholinergic intoxication secondary to organophosphate poisoning ( opc ) have been described . in the three cases described by joubert et al . , the extrapyramidal manifestations were limited to choreiform movements . although exact mechanism of action of propiconazole is not clear , but circumstantial evidence , low cholinesterase levels , and response to anticholinergic treatment sufficiently support our diagnosis . with delayed development of generalized chorea as neurological sequelae , propiconazole may be added as another compound in the causal list of toxic chorea widening the spectrum of acquired toxic causes of chorea still further . in a country like ours , where poisonings are frequent exposure to toxic agents