A 30-year-old, comatose male with miosis, diaphoresis, and incontinence

You are alerted that a 30-year-old, unconscious male is being brought by ambulance to the Emergency Department where you are on duty. While at home, the patient suddenly developed headache, dizziness, weakness, nausea, vomiting, and diarrhea. En route to the Emergency Department, he lost consciousness and experienced urinary and fecal incontinence.

When the patient arrives at the Emergency Department, you note that he has fixed pinpoint pupils, generalized paralysis, fasciculations, and is unresponsive to deep pain. Corneal and gag reflexes are absent. He has profuse salivation, diaphoresis, and excess lacrimation. Vital signs include the following: blood pressure 140/90 mm Hg, temperature 99.2°F (37.2°C), pulse 58 beats/minute and regular. Rales are noted during chest auscultation. Heart examination is unremarkable except for an S₄ gallop. Abdominal examination reveals no detectable masses, organomegaly, or hyperactive bowel sounds. Mucoid secretions are suctioned from the trachea at the time of intubation, and mechanical respiratory support is instituted. You initiate treatment with Narcan* for possible opiate ingestion, with no effect.

From the patient’s brother, you learn that the patient returned yesterday from a 5-day vacation in Arizona. This morning he changed into work clothes and began mixing pesticides for subsequent tree spraying in their family orchard. About noon, the patient became nauseated and started sweating profusely. The brother cannot recall any unusual events before his brother’s illness and assures you that they had performed the tree-spraying operations many times in the past with no ill effects.

After treatment and antidotal therapy, the patient improves remarkably—he has spontaneous respirations and regains consciousness within 4 hours. Mechanical ventilation is discontinued, and the patient is well enough to be discharged 3 days after admission.

Answers to the Pretest questions are on page 21.