Frågedatum: 1991-12-04
RELIS database 1991; id.nr. 7880, DRUGLINE
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A 6-year old boy have been medicated with Isopto-atropin (atropine) eye drops of 0.5 per cent, one



Fråga: A 6-year old boy have been medicated with Isopto-atropin (atropine) eye drops of 0.5 per cent, one drop in each eye in the mornings and evenings for 3 days. On the fourth day which also was the examination day the boy got by mistake the drug both in the eyes and in each nostril. He started with sneezing, itching in the eye, redness on the cheek, unclear speech and hallucinations. The boy was then taken under care. In the afternoon he became better. Is there any similar case in the literature?

Sammanfattning: The adverse systemic side effects (including dryness of skin and mouth; restlessness, irritability, delirium, hallucination; tachycardia; flushed skin of face and neck) after the topical application of atropine are documented in the medical literature. Considering the widespread use of atropine eye preparations, there are relatively few reports of either the systemic or ocular side effects. Children and the elderly seem to be particularly susceptible to the central-nervous system toxicity of atropine.

Svar: Hypersensitivity following the use of atropine eye drops has been documented, usually occurring in the form of contact dermatitis and conjunctival redness (1,2). Systemic absorption may lead to side effects including dryness of skin and mouth, fever (due to the inability to perspire), irritability or delirium (caused by stimulation of the central nervous system), flushing of the face (because of cutaneous vasodilation in the blush area), and tachycardia (resulting from vagal block) (1-3).

There are a few case reports of atropine poisoning in children after the use of atropine eye drops. However, majority of the reports date back to 50 years ago (cf 3). Nadal et al (4) reported a case of a 6-year-old boy of atropine intoxication. The boy was given 2 drops in each eye of an ophthalmic solution containing 2 per cent atropine sulphate (3 mg), 0.5 per cent scopolamine bromhydrate (0.75 mg), and 4 per cent phenylephrine hydrochloride (6 mg). One hour later the boy developed coma with agitation, dilated pupils, dry skin and mouth, facial flushing and progressively increased heart rate. After intravenous infusion of physostigmine the tachycardia decreased and the patient was discharged after 48 hours with a residual mydriasis (4).

Kortabarria and co-workers (5) reported a case of toxic psychosis in a 67-year-old woman who received 6-8 drops of cycloplegic eye preparation (12-16 mg atropine plus 3-3.5 mg scopolamine). After 15 minutes the patient developed symptoms including nausea, instability, temporal-spatial disorientation, verbosity with incoherent and disintegrated speech, changes in the tonality of the voice, dysarthria, agitation, and visual hallucinations with fabrications. The syndrome recovered 36 hours after its initiation.

The adverse drug reaction was confirmed following rechallenge at a similar dose (5).

Ninety cases of intentional ingestion of a plant called "the angel´s trumpet" containing belladonna alkaloids (atropine, hyoscyamine, and scopolamine) to achieve a hallucinogenic reaction had been reported in Florida (cf 2).

The systemic absorption of atropine after topical application may take place from both the conjunctiva of the eye and, after drainage through the nasolacrimal duct and by swallowing down the gastrointestinal tract. The peak plasma atropine concentration was reached within 8 minutes after ocular application in 8 patients, which is as rapid as that reported for intramuscular administration (6). It is estimated that a fatal dose of atropine varies from 100 mg for adults to 10 mg for children, but there is a considerable variation in individual susceptibility. Infants, young children and the elderly are especially susceptible to the toxic effects of atropinic drugs (cf 7). In children under 2 years of age and in the elderly a prolonged elimination of atropine has been found (8).

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