Delayed onset neuropathy along with recurrent laryngeal nerve palsy due to organophosphate poisoning and the role of physiotherapy rehabilitation
A 20-year-old female patient attempted suicide by ingesting a large amount of OP insecticide. She was admitted in a private hospital in an unconscious, gasping state with frothing from the mouth, smelling of insecticide. Pupils were miotic and fasciculations were evident. She was immediately intubated and was kept on synchronized intermittent mandatory ventilation (MV).\nSeven days later she was brought to Medical and Neurological Intensive care unit of our hospital on MV. On admission, she had poor respiratory effort. She was conscious, oriented, had grade four muscle power in upper and lower limbs, without sensory symptoms. On day 12, lobar pneumonia was diagnosed. She had copious purulent secretions which necessitated tracheostomy. She was treated with Piperacillin-Tazobactam. Chest physiotherapy along with respiratory muscle training by inspiratory muscle trainer with threshold resistance for strengthening of weak respiratory muscles proved an adjunct for the weaning off of the patient from mechanical ventilation. In stepdown care, her muscle power slowly reduced to grade two in upper limb and grade three in lower limb. Three days post-extubation, she developed rapid onset deterioration in muscle power to grade zero and absent deep tendon reflexes, but without respiratory deterioration. She developed bilateral foot drop and claw hand deformity. Nerve conduction studies indicated pure motor axonal neuropathy. Patient developed stridor when an attempt to close the tracheotomy was carried out. Bronchoscopy revealed tracheal stenosis 2.3 cm distal to the vocal chords along with bilateral adductor vocal cord paralysis indicating involvement of recurrent laryngeal nerve, which explains aphonia evident during partial closure trial of tracheostomy.\nForty five days from the ingestion of OP insecticide, she developed grade II spasticity according to Modified Ashwarth Scale in bilateral upper and lower limbs with flexor spasms in lower limbs and exaggerated deep tendon reflexes, which indicate pyramidal tract involvement. Sensitive symptoms of muscle pain, tenderness and cramps developed in bilateral quadriceps and calf muscles. This suggested the presence of OPIDN.\nPhysiotherapy was aimed at preventing neuro-musculoskeletal co-morbidity. Electrical stimulation with intermittent galvanic current was given to paralyzed distal muscles of upper and lower extremities to restore their properties and hence prevent further muscle wasting. Strengthening and proprioceptive neuromuscular facilitation for weak muscles, stretching of hand flexors and gastrosoleus and orthotic devices prevented further deformities. Tilt table supported standing helped to overcome the effects of prolonged bed rest and postural hypotension. After discharge the patient was referred to a community rehabilitation center for further management.\nMarital discord with violently abusive husband was the reason for this patient to attempt suicide. The patient and her relatives were counseled by psychiatrist. Her parents gave her emotional support and agreed to support her socially and financially. She was happy to separate from her husband.