nIUTISI1 MEDICAL JOURNAL VOLUME 285 . 14 AUGUST 190. reflexia and bilateral extensor plantar reflexes. Power in the legs was grade 2 inlialntion. These became sustained, and he was in cardiopulmonary arrcr and rc~naincdso during the clinical phase of tetnnus, with gmdual recovery on admission. Asystole was converted to ventricular fibrillation by intra subseq~~cntly.No sensory or sphincteric abnormality was observed during the venous injection of 2 ml of 1:1000 adrenaline and 10 ml 10% cnlciut: illness: glucol~ogalactogluconate. Cardioversion resulted in a supraventricula Tile patient was given 20 000 IU antitetanus serum intramuscularly after tacl~ycardia,which was converted to sinus rllythm by 10 mg sotalol give! a sensitisation test. Injections of diazepa~n,cl~lorpromazine, and pheno- intravenously. Spontaneous respiration- was not restored, and artificia barbitone \\'ere used to control the spasms, with adequate pare~~tcraland ventilation was instituted aftcr muscle relaxation by suxamcthonir~nl.Urin oral fccding. I-Ic made an uneventful recovery frorn tetanus, and about one analysis showed large amounts of strychnine."Ie remained deeply comatos month after onset plain radiography of the thoracol~lmbarspine, cerebro- but was free of convulsions. Nine hours after admission he had a fata spinal flttitl exnmination (including a Vcnerenl Disease Rescarcli Laboratory cartiiac arrest. test), and myelography sliowed notliing abl~orn~al.tie still had tlic facial l'hrec of the four rcmaining patients complained of pain and stiffness i~ palsy but could stand with support. IIypcrrcflcxin and extensor plantar the paravertebrnl rn:iscles within 30 minutes of inl~alation. Convulsions rcsponjes were still evitlcnt. At follow 111) two nlonths aftcr discllarge the charactcrisetl by :i .?:s sardonicus, opisthotonus, flexor spasm of upnci filcial palsy was barely tlisccrnible and IIC could malt: unaided. Mild hyper- limbs, and extc~l:.. -:Ism of lower limbs, occurrcd with minimal sensor) reflexin rvith equivocal plantar responses were elicited. Follow up at one year stimuli. They \Y !tcd in a quiet dark room. Dinzcparn 10 rng inrra shorved no neurological dclicit. verlously contrr::' .:~vulsionsand was repeated one hour later in twt patients in whorr: > ~ulsionsrecurred. Diazepanl was continued in an ora dose of 5 n~gsir l;::~rly,and the patients remained free of convulsions I-Iyperaestliesia antl hyperreflexia wit11 associated paravertebral myalgi: Commcnt persisted for 48 to 72 hours. Diazepam was discontinued 72 hours after This paticnt sllowcd the cllaractcristic featitrcs of tetanus, and 12 ad~nission.Serum creatine pl~osphokinascactivity was raised in all patient: (mean 1980 IU/I; normal < 130 IU/I), and estimation of isocnzymes showet' days bclorc onset he had injured his foot. In view of the paraplegia raised nluscle-type (Mhl) creatine kinase activity, indicating damage tc 1atl:yrislu was co~lsidmxl;lathyristn is comnlon in this region.' Tlie skeletal nluscle during the convulsions. Urine analysis showed moderatc patient denied eating seeds of L saliv~ls,there was no latl~yrismin the quantities of strychnine. family, the paraplcgia rcsolvcd, thcre was a facial nerve palsy, and he The remaining patient was only mildly affected. He cornplai;lcd of para- had tctanus-all going against the diagnosis of lathyrism. vertebral pain and stiffness. Tendon reflcxcs \vcre brisk but no convulsion.. Closrriditrirt rcrntri produccs two toxi~n,tetanospasrnin and tetnnoly- occurred, and specific treatment was not prescribed. Urine analysis showed sin. Tctanospasrnin interferes with inhibition within the central traces of strychnine. nervous systern and produces tl~eexcessive motor activity which Three patients were admitted to the Charitable Infirmary. All developed symptoms within 30 minutes of inhaling strychnine and were having inter- cliaracterises the disease. It may also protluce sonic of the auto- mittent convulsions on admission. Each was given intravenous diazepn~ir notnic dysfunction, espccially the syrnpatheticov~ractivity,~wllicl~ may 10 mg, phenoperidine 2 mg, and suxamethoniunl 100 mg. Artificial ventila- occur in severe cases. Paralysis, however, is unusu~lunless the wound tion using Cape Waine ventilators was instituted ant1 was cor~tir~uetlusing is on the face, vrhcn cranial nerve palsies, notably of the ipsilateral pancuronium for muscle relaxation and phcnoperidine and diazepanl for facial ~lndoculo~notor nerves, may occur. Paraplegia may occur if the sedation. Convulsions tended to recur as muscle tone recovered but mere tctanic spasms cause compression fracture of the spine, but our in- reatlily controlled with pancuronium. Urine analysis showed moderatc vcsti~:ations elirnirlated this and othcr compressive causes of paraplegia. anioilnts of strychnine in each case. After 36 hours, when strychnine was no longer tletected in the urine, artificial ventilation \\,as discoctinued. No It appears that the paraplegia is an unusual cffcct of tetanus as de- further convulsions occurred. All patients had rzised serum crearine phospho. scribed by Ualiem~ka.~?'he facial nerve palsy must also be attributed kiriase activity (mean 2797 IU/I; tlormal < 170 IU/I). Physical examination to tcra:lns, though it is unusual for this to occur when the wound is not showed no abnormality after 48 hours. or. the face. '. . . Gannpathy K.T, Dwivcdi MP. Studies on clinical epidemiology of latliy- Comment risni. In: Report of Lnrlryris~~rI:'ngr~iry Field Ui,it of Indian Corrncil of rlfe,I:'cal Research. Dcllli: ICMR, 1961:16-7. This report highlights a nlcdc of strychnine poisoning not prcvioitsly ' Kerr JH, Corbett JL, I'rys-Roberts C, Smith AC, Spalding JMK. described. Strychnine is now ra~clyaszd but tnay be stockcd by solnc Involven~ent of tlic synip:~tlletic nervous system in tetanus: stiidies on 82 cases. Lancrt 1968;ii:236. retail ~)liarmacics,so this type of accident might possibly recur. It is ' Balicn~ukaM. Acute transverse n~yclopathycomplicating tetanus. Postgrad not known how these patiens acquired the strgclmine, whicll was AledJ 198 1;57:443-4. inhnlcd apparcntly in mistake for cccaitle at a party. ~\l)artfrom thc patierit in whotn poisocine was fatal and the most ( AccrpteA 11 May 1982) mini~nallynITcctctl paticnt, who recovered witliout specific treatmctit,

- the remaining six paticnts were comparable in terms of degree of Degqrtment of Medicine, SS Medical College nnd Associnted GM inroxicatio~land urinary strychnine concentrations. In these pzticnts Ilosjjitnl, Rewn (1V11') 486001, India two tliKerent therapeutic regimens were us~tlwith equal sltcccss. M I( JAIN, ht~,lecturer Treatmerit with intravcnorts dlazepan in a quiet darkened room llas S ti KHXNIJO, MD, professor the advantage of bcing simpler than artificial ventilation, but if N K SIIARMA, bin, ns, postgraduate student diazcparn alone fails to control convulsions artificial ventilation should be instituted.

.i'hiencs CI-I, Haley TI. Cli~icaltoxicology. 5th ed. London: Kimpton 1972 :?4-6. Polson CJ, ~atters:~llZN. Cliuical foxicolo~y.2nd.,ed. 1-ondoli: Pirman Medical, 1969:558-68. U~ausualstrydlnia~e p~2ssming and Jackson G, Ng S'i, Diggle GE, Bourke IG. Strychcine poisoning treated i.ts successrully with diazepam. Llr Med J 1971 ;iii :5 19-20. traatmel-it: report of sight cases ' EIcrislianu Y, Landau If. Diazepam ;in the treatment of strychnine poisolling. Ur'J Atiaesth 1972;14:74748. Clnrke EGC. Isolnriolr orrd ider~!ificalio~~:f drugs. 1-ondon: Phnrmaceucical Strychnine is no\*! usccl rarely anti poisoning is unusnal. Intoxication l'ress, 1969:545. is usually accidental in children or srlicidal in adu1ts.l Trcatmcnt is I dircctcd towards coritrol of convulsio!is and prcverltiotl of aspliyxia, eitllcr by a short-acting barbiturate ant1 nlt~sclcrelaxarlt conlbincd with artificial vcntilntion? or by the tnorc rcccntly sticccssfill use of St Lnurcnce's IIospitaI, Dublin 7, Eire itltrnvc~lousdinzcpam alo~le.~'\Vc dcscribe eight cnscs of unusual W C 0'CAL.LAGI-IAN, btnc~r, registrar (now research fellow, Royal strychni~icpoisoning, threc of which wcre treated with intravcrlous Coilcgc of Surgeons in Ireland, Dublin 1) and four by nrtilicial ventilation. diazepam N JOYCE, LRCPI,1)~11, senior liouse ofliccr (now casualty 'officer) 1-1 E COUNII-IAN, hln, F*CP~, consultant physician

Casc reports 'Tlw Clia~.itableIn:irl:1:iry, Dublin 1, Eire h.1 WARD, nlrr, senior house officer in medicine (now scnior hoi~scofficer Eiql~tyoung atlults snifletl quantities of strycl~ninein the mistaken belief in gcrinrrics, .St Thomas's Ilospital, London) thnt it was cocaine. 1\11 dcvclol,etl toxic symptonls within 30 minutes 311d 1' 1-i\Vi:I-L.E, wnncsr, registrar in a~raestl~c~ics(ncw senior registrar in were adn~ittc~lto two I)~lblil~I~ospitals. anacstllclics, Cur!< lZcgio~l:~lI4crsl1ilal, Cork) I:ire patients \.:ere nd~nittctlto St 1,aurcncc's Ilospital. Tl~cInail who llad E O'IIKIl:.N, AIRCI-, r;ltcpr, consult:uit physician . take11 tlrc Iitrgcst qr~antitydcvelopctl conv~llsionswithin live nlinutcs of