Discussion
This case exemplifies several issues that can arise when diagnosing
toxic psychosis caused by orally administered hyoscine. Hyoscine is
usually prescribed in adult patients for the treatment of abdominal pain
associated with cramps induced by gastrointestinal (GI) spasms. It is an
antimuscarinic medication that works similarly to atropine. It is made
from a belladonna alkaloid (Atropa belladonna, commonly known as deadly
nightshade). It antagonizes acetylcholine at muscarinic receptors at
therapeutic doses, but it can also antagonize nicotinic receptors at
high doses.7
Confusion, hallucination, fatigue, short-term memory loss, difficulty
urinating, blurred vision, skin redness, and changes in heart rate are
all common complications or side effects of hyoscine
butylbromide.8 A person suffering from anticholinergic
intoxication can be described as ”red as a beet, hot as a hare, dry as a
bone, blind as a bat, mad as a hatter.” This is a representation of a
patient’s flushed skin, hyperthermia, dry mucous membranes, blurred
vision, and confusion or delirium.9 Most cases of
hyoscine intoxication can be treated by stopping the offending drug and
providing supportive care to lower the patient’s fever, keep them cool,
and keep them hydrated. Benzodiazepines can be used to reduce agitation
and restlessness in patients. Patients who have toxic psychosis for up
to 48 hours and are a danger to themselves and others may need to be
admitted to the hospital for close monitoring and
management.10 In our case, however, the patient
recovered completely after the drug was stopped for 24 hours. Due to
laboratory limitations, the serum level of hyoscine was not measured.
Poonai et al. randomly assigned children aged 8–17 years with
nonspecific colicky abdomen pain who reported to the pediatric emergency
department at London Health Sciences Centre in London, Ontario, to
receive hyoscine butyl bromide, 10 mg orally, or acetaminophen, 15 mg/kg
orally (maximum 975 mg). In this study, hyoscine butyl bromide did not
outperform acetaminophen. 32/116 (27.6 percent) of individuals in the
hyoscine butylbromide group experienced adverse reactions in the
emergency department. Nausea, vomiting, dizziness, and photosensitivity
were common adverse effects. There were no significant side
effects.11
Anticholinergic-induced agitation, delirium, and hallucinations are
treated with physostigmine, an acetylcholinesterase
inhibitor.12,13 While the patient is being observed, a
test dose of physostigmine, usually 0.5 or 1 mg, can be given
intramuscularly, subcutaneously, or
intravenously.14,15 Arrhythmias or hypotension caused
by the physostigmine-induced cholinergic crisis should be monitored
closely. Before prescribing physostigmine, it’s important to rule out
any potential contraindications like renal hypertension,
hyperthyroidism, diabetes, or coronary artery disease.