A rarely described use of neostigmine in a case of acute anticholinergic poisoning.

Introduction Anticholinergic poisoning can require administration of an antidote. The classical antidote used is the anticholinesterase, physostigmine [1]. Another anticholinesterase, neostigmine, has been less described for this indication [2]. Tropatepine (Lepticur) is a synthetic molecule used in the treatment of Parkinson's disease or to correct Parkinson syndromes induced by neuroleptic drugs [3]. This anticholinergic drug has side effects of xerostomia, difficulty focusing, ocular hypertension, micturition disorders, constipation, hallucination, confusion, mental disorders at recommended doses as well as in overdosage [4]. The latter, however, are rarely described, since this treatment is mainly used in Europe. The authors describe a case of acute anticholinergic poisoning with tropatepine, which responded well to antidote treatment using neostigmine. Observation A suicidal female patient of 17 years old usually treated with loxapine and tropatepine took 30 tablets of Lepticur 10 mg (brand name of the molecule in France), i.e. 300 mg of tropatepine, as well as 8 g of paracetamol. Her parents drove her rapidly to the emergency department. Two hours post-ingestion, she was still asymptomatic and was given activated charcoal on the advice of the poison control centre. Four hours postingestion, she showed severe signs of atropinism: tachycardia, agitation and muscular hypertonia of the limbs, hyperthermia at 38.2 8C, mydriasis with confusion, and without seizures. One milligram clonazepam was injected intravenously as well as an antidote treatment of 0.5 mg neostigmine given by intravenous infusion, physostigmine being unavailable. This antidotal treatment was repeated 20 min later. During this 20 minutes second infusion, a marked clinical improvement of all symptoms was noticed. A relapse into these neurological signs (especially agitation, confusion and mydriasis) was noted 21 h post-ingestion. Therefore, a third dose of 0.5 mg of neostigmine was