Neem oil poisoning: Case report of an adult with toxic encephalopathy
A 73-year-old man with the medical history of diabetes mellitus type 2 and psoriasis presented to the emergency department with complaints of vomiting and drowsiness, 1 hour after accidental ingestion of 20 ml of Neem oil. The patient's current medication included human Mixtard insulin (30/70), 16 U before breakfast and 10 U before dinner.\nAt presentation, the patient was drowsy with Glasgow coma scale of 13/15. His pulse rate was 110/min, respiratory rate 28/min, oxygen saturation of 95% at room air, and blood pressure 150/90. Physical examination was unremarkable. Systemic examination showed: bilateral equal and reacting pupils with no meningeal signs and no focal neurological deficits. Respiratory, Cardiovascular and abdominal examination were unremarkable.\nIn the emergency department, the patient developed generalized convulsions with loss of consciousness. He was intubated and managed initially with intravenous lorazepam. In the intensive care unit, he was managed with insulin and symptomatic treatment.\nInvestigations at presentation showed: Hemoglobin 13.3 gm/dl, leukocyte leukocyte count 16800/μl, red blood cell count 4.41 million/cmm, platelet count 375000/μl, blood sugar 298 mg/dl, serum osmolality 277 mosmol/kg, and normal serum lactate level. An arterial blood gas analysis showed metabolic acidosis: pH 7.34, pO2 81, pCO2 24, HCO3 16, and pO2/FiO2 385. He had normal urine analysis, serum electrolytes, liver, renal, and thyroid function. MRI scans of brain showed chronic ischemic changes due to small vessel disease. ECG and radiograph of the chest were normal.\nInvestigations repeated on day 2, 3, and on discharge showed: Normal electrolytes, arterial blood gas, liver, and renal function. During the course of illness, he remained drowsy for 4 days and recovered without any complications. He was discharged after 1 week.