Presence and Abatement of Tongue Fasciculations
Tongue Fasciculations in Organophosphate Poisoning A 15-year-old boy who lived with his family on a farm presented to the emergency department with a 1-day history of vomiting, diarrhea, and altered sensorium. On initial assessment, he was drowsy and had tachypnea and hypotension. Auscultation of the lungs revealed diffuse crepitations. His pupils were reactive, equal in size, and mildly constricted (4 mm in diameter). There was no focal neurologic deficit. During insertion of a feeding tube, diffuse tongue fasciculations were noted (Video 1). Further investigation revealed mild anemia, an elevated white-cell count, and low plasma levels of cholinesterase. The cholinergic symptoms, tongue fasciculations, and farming background of the family suggested a diagnosis of organophosphate poisoning. The patient was treated with atropine, intravenous fluids, and inotropic agents. Atropine was administered for 48 hours and then gradually tapered after clinical improvement and abatement of symptoms (Video 2). The patient stated that he had ingested an insecticide solution (which contained 2,2-dichlorovinyl dimethyl phosphate) with suicidal intent owing to poor performance at school. Organophosphates inhibit acetylcholinesterase, which results in the accumulation of acetylcholine at various receptors in the nervous system. Fasciculations result from overstimulation of the nicotinic receptors at the neuromuscular junction.
