Correspondence

Case 12-2001: Strychnine Poisoning

N Engl J Med 2001; 345:1577November 22, 2001

Article

To the Editor:

In an otherwise excellent discussion of strychnine poisoning in Case 12-2001 (April 19 issue),1 a diagnosis is assigned that is unsupported by the data provided. The case concerned a 16-year-old boy with confusion. The boy, who was born in Cambodia, had been given an herbal preparation that contained strychnine. The presentation was entirely consistent with strychnine poisoning, which is recorded as one of the anatomical diagnoses. However, for unclear reasons, the patient was also given an anatomical diagnosis of bipolar disease. This diagnosis is almost certainly wrong.

The changes in the mental state of the patient — intermittent agitation, delusions, fearfulness, and disorientation — are best accounted for by a diagnosis of delirium. The fact that these signs continued for “several days” after the neuromuscular symptoms resolved is not inconsistent with this diagnosis. The delirium was most likely due to a number of factors, including the direct effects of the postsynaptic blockade of glycine caused by strychnine, the systemic effects of the prolonged muscle contraction, and the medications used. Although the subsequent improvement in mental status was attributed to risperidone treatment, it is likely that the delirium would have improved without the administration of any psychotropic drugs.

Christopher James Ryan, M.B., B.S., F.R.A.N.Z.C.P.
University of Sydney, Sydney, NSW 2006, Australia
cryan@mail.usyd.edu.au

Josephine Anderson, B.Med., F.R.A.N.Z.C.P.
Westmead Hospital, Sydney, NSW 2145, Australia

1 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 12-2001). N Engl J Med 2001;344:1232-1239
   Full Text | Web of Science | Medline