Cholinergic crisis following administration of distigmine bromide : a case report

78歳男.心窩部痛を主訴に上部消化管内視鏡検査で十二指腸潰瘍を指摘され入院し, 夜間頻尿を訴えた.炎症反応および肝機能障害を認め, 超音波検査で残尿と軽度前立腺肥大症を, 膀胱内圧測定で排尿筋括約筋協調不全が示唆された.神経因性膀胱による排尿障害を疑い臭化ジスチグミンを投与し症状の改善を認めたが, 著明な発汗, 呼吸困難および意識障害を生じ高濃度酸素投与を開始した.更に徐脈, チアノーゼ, 流涙, 気道分泌亢進, 縮瞳, 意識レベル低下など副交感神経刺激症状が生じショック状態に陥り, 臭化ジスチグミンによるコリン作動性クリーゼが疑われた.投与を直ちに中止し人工呼吸管理, 硫酸アトロピン投与および新鮮凍結血漿輸血を行ったが一時的心肺停止に陥り, 心肺蘇生術を施行するも一時的ChE値上昇は認めたが, 再度血圧低下とともにChE値が低下し死亡した
The long-acting anticholinesterase, distigmine bromide (Ubretid), is widely used for the treatment of underactive neurogenic bladder. Therefore, we emphasize its hazardable side-effect of cholinergic crisis. A 78-year-old man with duodenal ulcer complained of nocturia, and was administered distigmine bromide 10 mg daily under the diagnosis of mild benign prostatic hypertrophy with underactive neurogenic bladder. It seemed that administration slightly improved his symptom but he developed bradycardia, dyspnea and drowsiness suddenly on the 4th day. Blood examination revealed extremely low cholinesterase in his serum, suggesting distigmine bromide intoxication. He was treated intensively with several intravenous injections of atropine, high-concentration oxygen and transfusion of fresh frozen plasma. Nevertheless, his condition did not recover, resulting in death of "cholinergic crisis" on the 6th day.