Case 23 – Garlic Breath

Case #23: Garlic Breath
Author: Jason Murphy, MD
Peer Reviewer: Frank Paloucek, MD

A pair of brothers, 6 and 9 years old, present to your ED. Neither child has any significant past medical history. They were playing unsupervised at their grandfather’s old, run-down farm when they were found to be “acting strange” per their parents. They are both responsive and give vague and inappropriate answers. The exam is significant for profuse sweating, pinpoint pupils, and copious oral secretions. As you get closer, you think you smell the faint odor of garlic.

What is the most likely cause of the children’s symptoms?
The combination of pinpoint pupils with profuse sweating support cholinergic toxicity. In light of the history of playing on an “old farm”, combined with a “garlic odor”, you should have a high suspicion for organophosphate (pesticide) poisoning.

Other toxic chemicals found on farms (fertilizers, hydrocarbons, etc.), though worrisome, are less likely to cause these findings.

What is the mechanism of action of the substance in question?
Organophosphates bind to acetylcholinesterase (AchE), causing elevated levels of Ach, which stimulate both the muscarinic and nicotinic receptors throughout the body. Initially, the binding is reversible. However, with time, “aging” occurs, leading to irreversible inactivation of AchE. Pralidoxime, although controversial in terms of efficacy, is thought to prevent this “aging” process by inhibiting binding of the organophosphate to AchE.
When faced with an exposure such as this, what is the first thing you must do?
Protect yourself and other healthcare workers, by applying personal protective equipment (PPE) and decontaminating the patient. There are numerous case reports of health care workers becoming sick after caring for patients with organophosphate exposure. Exposure can occur through skin contact, inhalation, emesis, and other contact with body fluids. It is important to stay safe so that you can take care of these and other patients.
What symptoms do you expect to find as you examine both children?
The symptoms with associated with cholinergic toxicity can be remembered with either of two mnemonics: ‘SLUDGE and The Killer B’s’ or ‘DUMBELS’.


Bronchial constriction*

Miosis/Muscle weakness
Bronchorrhea*/Bronchial constriction*/Bradycardia**

*Note: Of the symptoms above, bronchorrhea and the bronchial constriction are the most life-threatening in the immediate post-exposure period.

**Note: Some patients with cholinergic toxicity can present with tachycardia (especially, at the initial onset).

Both children are exhibiting signs of respiratory distress and inability to control their secretions. What medication should you give?
Give atropine. Atropine competes with acetylcholine at the muscarinic receptors which should counteract most of the patient’s symptoms. Patients may require HUNDREDS of milligrams of atropine and it is important to recall that the goal of atropine is to prevent bronchial secretions and constrictions from causing respiratory failure, not to increase the heart rate. Tachycardia is NOT a contraindication to atropine.

If there is any concern that the patient is unable to control their secretions, you need to be prepared to intubate. AVOID succinylcholine due to the potential for a severely prolonged half life (lasting hours to days) due to inhibition of plasma cholinesterase, the enzyme that metabolizes succinylcholine.


Asari Y, Kamijyo Y, Soma K. Changes in the hemodynamic state of patients with acute lethal organophosphate poisoning. Vet Hum Toxicol. 2004 Feb;46(1):5-9.

Aygun D. Diagnosis in an acute organophosphate poisoning: report of three interesting cases and review of the literature. Eur J Emerg Med. 2004 Feb;11(1):55-8.

Eddleston M, Roberts D, Buckley N. Management of severe organophosphorus pesticide poisoning. Crit Care. 2002 Jun;6(3):259.

Eddleston M, Szinicz L, Eyer P, et al. Oximes in acute organophosphorus pesticide poisoning: a systematic review of clinical trials. QJM. 2002 May;95(5):275-83.

Eyer P. The role of oximes in the management of organophosphorus pesticide poisoning. Toxicol Rev. 2003;22(3):165-90.

Sidell FR. Clinical effects of organophosphorus cholinesterase inhibitors. J Appl Toxicol. 1994 Mar-Apr;14(2):111-3.

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