Clinical and electrophysiological study of neuropathy after organophosphorus compounds poisoning

Improving Anti-Neurodegenerative Benefits of Acetylcholinesterase Inhibitors in Alzheimer's Disease: Are Irreversible Inhibitors the Future?

Decades of research have produced no effective method to prevent, delay the onset, or slow the progression of Alzheimer's disease (AD). In contrast to these failures, acetylcholinesterase (AChE, EC 3.1.1.7) inhibitors slow the clinical progression of the disease and randomized, placebo-controlled trials in prodromal and mild to moderate AD patients have shown AChE inhibitor anti-neurodegenerative benefits in the cortex, hippocampus, and basal forebrain. CNS neurodegeneration and atrophy are now recognized as biomarkers of AD according to the National Institute on Aging-Alzheimer's Association (NIA-AA) criteria and recent evidence shows that these markers are among the earliest signs of prodromal AD, before the appearance of amyloid. The current AChE inhibitors (donepezil, rivastigmine, and galantamine) have short-acting mechanisms of action that result in dose-limiting toxicity and inadequate efficacy. Irreversible AChE inhibitors, with a long-acting mechanism of action, are inherently CNS selective and can more than double CNS AChE inhibition possible with short-acting inhibitors. Irreversible AChE inhibitors open the door to high-level CNS AChE inhibition and improved anti-neurodegenerative benefits that may be an important part of future treatments to more effectively prevent, delay the onset, or slow the progression of AD.

Anticholinergic Drugs – Functional Antidotes for the Treatment of Tabun Intoxication

1. To study the influence of antidotes on tabun-induced neurotoxicity, the rats were injected intramuscularly with organophosphate tabun (LD50). The efficacy of choice antidotal treatment consisting of acetylcholinesterase reactivator obidoxime and one of four anticholinergic drugs (atropine, benactyzine, biperiden, scopolamine) was compared. 2. Testing of tabun-induced neurotoxicity progress was carried out using the method Functional observational battery. The experimental animals as well as controls were observed at 24 hours and 7 days following tabun or saline administration. 3. The results were compared to the condition of animals without anticholinergic drug (oxime alone) and control rats that received physiological solution instead of tabun and treatment. Antidotal treatment involving centrally acting anticholinergic drugs (benactyzine, biperiden, scopolamine) showed significantly higher neuroprotective efficacy compared to antidotal treatment containing atropine.

Characterization of human cytochrome P450s involved in the bioactivation of tri-ortho-cresyl phosphate (ToCP)

Tri-ortho-cresyl phosphate (ToCP) is a multipurpose organophosphorus compound that is neurotoxic and suspected to be involved in aerotoxic syndrome in humans. It has been reported that not ToCP itself but a metabolite of ToCP, namely, 2-(ortho-cresyl)-4H-1,2,3-benzodioxaphosphoran-2-one (CBDP), may be responsible for this effect as it can irreversibly bind to human butyrylcholinesterase (BuChE) and human acetylcholinesterase (AChE). The bioactivation of ToCP into CBDP involves Cytochrome P450s (P450s). However, the individual human P450s responsible for this bioactivation have not been identified yet. In the present study, we aimed to investigate the metabolism of ToCP by different P450s and to determine the inhibitory effect of the in vitro generated ToCP-metabolites on human BuChE and AChE. Human liver microsomes, rat liver microsomes, and recombinant human P450s were used for that purpose. The recombinant P450s 2B6, 2C18, 2D6, 3A4 and 3A5 showed highest activity of ToCP-bioactivation to BuChE-inhibitory metabolites. Inhibition experiments using pooled human liver microsomes indicated that P450 3A4 and 3A5 were mainly involved in human hepatic bioactivation of ToCP. In addition, these experiments indicated a minor role for P450 1A2. Formation of CBDP by in-house expressed recombinant human P450s 1A2 and 3A4 was proven by both LC-MS and GC-MS analysis. When ToCP was incubated with P450 1A2 and 3A4 in the presence of human BuChE, CBDP-BuChE-adducts were detected by LC-MS/MS which were not present in the corresponding control incubations. These results confirmed the role of human P450s 1A2 and 3A4 in ToCP metabolism and demonstrated that CBDP is the metabolite responsible for the BuChE inactivation. Interindividual differences at the level of P450 1A2 and 3A4 might play an important role in the susceptibility of humans in developing neurotoxic effects, such as aerotoxic syndrome, after exposure to ToCP.

Identifying safer anti-wear triaryl phosphate additives for jet engine lubricants

Individuals aboard jet aircraft may be exposed to potentially toxic triaryl organophosphate anti-wear lubricant additives (TAPs) that are converted by cytochromes P450 into toxic metabolites. Consequences of exposure could be reduced by using less toxic TAPs. Our goal was to determine whether an in vitro assay for inhibition of butyrylcholinesterase (BChE) by bioactivated TAPs would be predictive of inhibition of serine active-site enzymes in vivo. The in vitro assay involved TAP bioactivation with liver microsomes and NADPH, followed by incubation with human BChE and measurement of BChE activity. Of 19 TAPs tested, tert-butylated isomers produced the least BChE inhibition. To determine the relevance of these results in vivo, mice were exposed to Durad 125 (D125; a commercial mixture of TAP esters) or to TAPs demonstrating low or no BChE inhibition when assayed in vitro. Inhibition of BChE by bioactivated TAPs in vitro correlated well with inhibition of other serine active-site enzymes in vivo, with the exception of brain acetylcholinesterase and neuropathy target esterase (NTE), which were not inhibited by any TAP tested following single exposures. A recombinant catalytic domain of NTE (rNEST) exhibited classical kinetic properties of NTE. The metabolite of tri-(o-cresyl) phosphate (ToCP), 2-(o-cresyl)-4H-1,3,2-benzodioxaphosphoran-2-one (CBDP), inhibited rNEST in vitro, but with an IC(50) value almost 6-times higher than for inhibition of BChE. Physiologically-relevant concentrations of the flavonoid naringenin dramatically reduced D125 bioconversion in vitro. The in vitro assay should provide a valuable tool for prescreening candidate TAP anti-wear additives, identifying safer additives and reducing the number of animals required for in vivo toxicity testing.

Delayed neurotoxicity - do trichlorphon and/or dichlorvos cause delayed neuropathy in man or in test animals?

Many, but not all, reports of delayed neuropathy associated with acute poisoning by trichlorphon refer to cases in U.S.S.R. Adulteration of technical trichlorphon with the ethyl analogue would greatly increase the neurotoxic hazard but analysis of a few samples has not revealed such impurities. Simultaneous ingestion of alcohol does not appear to increase neuropathic hazard. In hens double doses of trichlorphon each exceeding unprotected LD50 can produce moderate neuropathy associated with appropriately high inhibitions of neurotoxic esterase. Similar results are obtained with 2 doses of 10 x LD50 of dichlorvos. In vitro the inhibitory power of dichlorvos against neurotoxic esterase of hen brain is 0.02 x the power against acetylcholinesterase. This ratio correlates reasonably with the ratio of LD50/neuropathic dose. The factor for human brain enzymes is 0.06 suggesting that man is more susceptible to neuropathic effects of near-lethal doses of circulating dichlorvos. It is concluded that the only neuropathic hazard to man from good quality trichlorphon arises from rapid ingestion of massive doses. To obtain critical levels of inhibition of neurotoxic esterase and to cause neuropathy in man by repeated doses would require each dose to be severely toxic. Dichlorvos ingested in large doses is likely to kill rather than to cause neuropathy.

Historical Neurotoxins: What We Have Learned from Toxins of the Past About Diseases of the Present

Throughout history, humans have fallen victim to a variety of neurotoxins, with exposures coming in the form of tainted products, industrial pollution, drugs of abuse, and even the bread and water that sustain them. Despite this long and tumultuous history, neurotoxic outbreaks still occur with regular frequency. Although many difficulties currently exist in linking many of today's unexplained neurologic disorders to toxins, the past suggests a prominent role for neurotoxins in diseases (such as amyotrophic lateral sclerosis and PD), unexplained peripheral neuropathies, neurodevelopmental disorders, and many psychiatric disturbances.

Organophosphate-Induced Delayed Polyneuropathy

Organophosphate-induced delayed polyneuropathy (OPIDP) is a rare toxicity resulting from exposure to certain organophosphorus (OP) esters. It is characterised by distal degeneration of some axons of both the peripheral and central nervous systems occurring 1-4 weeks after single or short-term exposures. Cramping muscle pain in the lower limbs, distal numbness and paraesthesiae occur, followed by progressive weakness, depression of deep tendon reflexes in the lower limbs and, in severe cases, in the upper limbs. Signs include high-stepping gait associated with bilateral foot drop and, in severe cases, quadriplegia with foot and wrist drop as well as pyramidal signs. In time, there might be significant recovery of the peripheral nerve function but, depending on the degree of pyramidal involvement, spastic ataxia may be a permanent outcome of severe OPIDP. Human and experimental data indicate that recovery is usually complete in the young. At onset, the electrophysiological changes include reduced amplitude of the compound muscle potential, increased distal latencies and normal or slightly reduced nerve conduction velocities. The progression of the disease, usually over a few days, may lead to non-excitability of the nerve with electromyographical signs of denervation. Nerve biopsies have been performed in a few cases and showed axonal degeneration with secondary demyelination. Neuropathy target esterase (NTE) is thought to be the target of OPIDP initiation. The ratio of inhibitory powers for acetylcholinesterase and NTE represents the crucial guideline for the aetiological attribution of OP-induced peripheral neuropathy. In fact, pre-marketing toxicity testing in animals selects OP insecticides with cholinergic toxicity potential much higher than that to result in OPIDP. Therefore, OPIDP may develop only after very large exposures to insecticides, causing severe cholinergic toxicity. However, this was not the case with certain triaryl phosphates that were not used as insecticides but as hydraulic fluids, lubricants and plasticisers and do not result in cholinergic toxicity. Several thousand cases of OPIDP as a result of exposure to tri-ortho-cresyl phosphate have been reported, whereas the number of cases of OPIDP as a result of OP insecticide poisoning is much lower. In this article, we mainly discuss OP pesticide poisoning, particularly when caused by chlorpyrifos, dichlorvos, isofenphos, methamidophos, mipafox, trichlorfon, trichlornat, phosphamidon/mevinphos and by certain carbamates. We also discuss case reports where neuropathies were not convincingly attributed to fenthion, malathion, omethoate/dimethoate, parathion and merphos. Finally, several observational studies on long-term, low-level exposures to OPs that sometimes reported mild, inconsistent and unexplained changes of unclear significance in peripheral nerves are briefly discussed.

Chronic effects of low level exposure to anticholinesterases--a mechanistic review

High dose exposure to anticholinesterases which results in symptomatic poisoning can have lasting consequences due to the trauma of intoxication, excitotoxicity, secondary hypoxic damage, and (for some agents) a delayed onset polyneuropathy (OPIDN). The potential effects of low level exposure are less well defined. The most reliable data comes from controlled clinical trials with specific agents. A single dose of sarin or repeated doses of metrifonate or mevinphos, have produced only transient adverse effects at doses causing substantial acetylcholinesterase inhibition. Other data comes from epidemiological surveys. These have often used more sensitive indices than the clinical studies, but are less reliable due to the difficulty of defining exposure and matching control and exposed populations. Subtle, mainly cognitive, differences between exposed and non-exposed populations are sometimes seen. Low level exposure can cause a reversible down-regulation of cholinergic systems, and a range of non-cholinesterase effects that are structure-specific, and do not always parallel acute toxicity. Novel protein targets sensitive to low level exposure to some organophosphates are known to exist in the brain, but their functional significance is not yet understood.

Poisoning by organophosphorus insecticides and sensory neuropathy

OBJECTIVES

Poisoning by organophosphate insecticides causes cholinergic toxicity. Organophosphate induced delayed polyneuropathy (OPIDP) is a sensory-motor distal axonopathy which usually occurs after ingestion of large doses of certain organophosphate insecticides and has so far only been reported in patients with preceding cholinergic toxicity. Surprisingly, it was recently reported by other authors that an exclusively sensory neuropathy developed in eight patients after repeated unquantified exposures to chlorpyrifos, which did not cause clear-cut cholinergic toxicity. The objective was to assess whether an exclusively sensory neuropathy develops in patients severely poisoned by various OPs.

METHODS

Toxicological studies and electrophysiological measurements were performed in peripheral motor and sensory nerves in 11 patients after acute organophosphate poisoning among which two subjects were poisoned with chlorpyrifos.

RESULTS

Three patients developed OPIDP, including one poisoned by chlorpyrifos. Exclusively sensory neuropathy was never seen after either single or repeated acute organophosphate poisoning. A mild sensory component was associated with a severe motor component in two of the three cases of OPIDP, the other was an exclusively motor polyneuropathy.

CONCLUSION

A sensory-motor polyneuropathy caused by organophosphate insecticides might occur after a severe poisoning and the sensory component, if present, is milder than the motor one. Bearing in mind the toxicological characteristics of these organophosphate insecticides, other causes should be sought for sensory peripheral neuropathies in patients who did not display severe cholinergic toxicity a few weeks before the onset of symptoms and signs.

October 1942: a strange epidemic paralysis in Saval, Verona, Italy. Revision and diagnosis 50 years later of tri-ortho-cresyl phosphate poisoning

In the autumn of 1942 a strange epidemic paralysis started in Saval, at that time a country area but now part of the city of Verona. The epidemic went on for several months and affected 41 people, all working as owners or labourers on the same farm. Some of the farm animals (chickens, horses, cattle, pigs) also became ill. About 20 patients were admitted to the nearby city hospital. The outbreak was diagnosed as polyneuritis with a probable viral cause. Fifty years later, seven people with sequelae of the disease were examined. The most severe cases present a spastic paraplegia and lower leg muscle atrophy without sensory impairment, resembling an amyotrophic lateral sclerosis "frozen" for 50 years. The clinical syndrome can now be attributed confidently to organophosphate induced delayed polyneuropathy. All the epidemiological data obtained from the survivors were evaluated and a careful review of the literature was made. Contamination of the ground from a rubbish dump near the farmyard would explain the epidemiology of the Saval outbreak.

The pathogenesis of organophosphate polyneuropathy

This review discusses the facts regarding organophosphate-induced delayed polyneuropathy (OPIDP) as they are related to its pathogenesis rather than being a comprehensive review of all available data. Neuropathy target esterase (NTE) is considered to be the molecular target for OPIDP which is affected by several esterase inhibitors. Such inhibitors are ranked according to their toxicological effects as follows: 1. Phosphates, phosphoroamidates, and phosphonates cause OPIDP when high amounts of NTE are inhibited. In most cases 70 to 80% inhibition is enough, whereas in others much more is required. 2. Phosphinates, carbamates, and sulfonyl halides cause either protection from or promotion of OPIDP when given before or after a neuropathic OP, respectively. Both effects are related to doses that inhibit NTE. Neuropathy is also caused by the combined treatment with a carbamate and a sulfonyl fluoride. The potency of a given NTE inhibitor to cause OPIDP is related to the chemistry of the residue left attached to NTE, in addition to its affinity for the enzyme. The capability of inhibited NTE to undergo the aging process distinguishes inhibitors with high from those with negligible or very low potency to cause OPIDP. Therefore, protection from neuropathic doses of effective OPs is obtained when NTE is mostly inhibited with nonageable inhibitors. Promotion of OPIDP is likely to involve another site besides NTE because it might occur when almost all NTE is affected. Promotion affects either progression or expression of OPIDP after the initial biochemical lesion on NTE. Since only NTE inhibitors have been proven to be promoters, it is possible that this site is made available after the initiation of OPIDP and that it may have biochemical properties indistinguishable from those of NTE of naïve birds. Age-related resistance to OPIDP also seems to be related to either progression or expression of OPIDP and/or to the different physiology of NTE at a given age. Previously reported resistance of rats to clinical OPIDP seems also to be age-dependent. The physiological function(s) of NTE is unknown, but some practical gains have been obtained from its identification, including OPIDP risk assessment and biomonitoring.

A review of organophosphate poisoning

Many organophosphate compounds are pesticides widely used for the control of insect vectors. They are not ideal agents because they lack target vector selectivity, and have caused severe toxicity and even death in humans and domestic animals. Their toxicity has been recognised since the 1930s, when they were also developed for use as chemical warfare agents. The mechanism of action of organophosphates has been determined in some depth; the understanding of the toxic effects resulting from the inhibition of cholinesterase activity, causing accumulation of acetylcholine at nerve endings has played a major part in providing a rationale for specific antidote treatment using atropine and oximes. However, the most suitable oxime for reactivation of cholinesterases has still not been established with certainty, although pralidoxime is widely recommended. Chronic toxicity, particularly the neuropathic effects, merits further study because it contributes substantially to the long term morbidity in cases of severe acute, or chronic, exposure. Prevention of potentially toxic organophosphate exposure, particularly amongst employees in industries manufacturing or using the compounds and in the most susceptible groups of the population, such as the young and the elderly, should be sought wherever possible. Government authorities should be encouraged to control organophosphate product licensing, manufacture, storage, import, methods of use and delivery, food contamination and disposal.

Assessment of organophosphorus-induced delayed neuropathy in chickens using needle electromyography

The adult chicken provides the generally accepted animal model for organophosphorus-induced delayed neuropathy, exhibiting both clinical signs and histopathological damage after exposure. In this study, noninvasive electrodiagnostic methods were used for assessment of the development of neuropathy after administration of a single dose of protoxicant tri-ortho-tolyl phosphate (TOTP, 360 and 500 mg/kg po) and active congener phenyl saligen phosphate (PSP, 2.5 and 6 mg/kg im). Onset and severity of clinical signs were dose-related for both organophosphorus compounds. Extensive peripheral nerve lesions consistent with advanced stages of organophosphorus-induced delayed neuropathy were noted in selected chickens examined 19 d after TOTP administration. Needle electromyographic examinations of gastrocnemius, anterior tibialis, semitendinosus, and semimembranosus muscles were done before exposure and on d 8, 15, and 19 after exposure to TOTP and on d 8, 15 and 17 after exposure to PSP. Untreated chickens (negative controls) were also examined at each session. An untreated chicken with a transected sciatic nerve (positive control) was examined on d 13, 20, and 23 posttransection. Prolonged insertional activities were found in both treated and untreated chickens. Denervation potentials were found in only 2 of the 20 chickens administered organophosphates. Denervation potentials were, however, easily visible 13 d following transection of the sciatic nerve of a normal chicken. Needle electromyography could not evaluate organophosphorus-induced delayed neuropathy in chickens of this study.

Organophosphate-mediated inhibition of choline acetyltransferase activity in rat brain tissue

Administration of the organophosphate compound soman in rats resulted in an inhibition of choline acetyltransferase activity in almost all brain regions examined. Enzyme activity was inhibited by 20-50% in various brain regions 30 min after soman injection (94-120 micrograms/kg). Enzyme activity in two regions decreased with time to a near zero level by 3 h after injection.

In vivo distribution of 14C radiolabeled soman [3,3-dimethyl-2-butoxy)-methylphosphorylfluoride) in the central nervous system of the rat

Radiolabeled 14C soman, a potent anticholinesterase, was administered to rats at a dose of 0.75 LD50 (17.3 micrograms/kg, i.m.). Prior to being quick frozen, the animals were held for 2 min, 32 min or 48 h after dosing. Analysis of autoradiographs taken from cryostat sections through the central nervous system (CNS) showed that at 2 and 32 min radiolabel was primarily distributed in the blood, the choroid plexus and the cerebrospinal fluid (CSF), with several brain nuclei showing small increases in labeling density. At 48 h there was marked accumulation of radiolabel in the caudate and accumbens nuclei compared to all other brain areas. The above results showed little similarity between cholinesterase localization and distribution of radiolabel.

Delayed neuropathy after organophosphorus insecticide (Dipterex) poisoning: a clinical, electrophysiological and nerve biopsy study

Clinical, electrophysiological and histological findings in four patients accidentally poisoned with the organophosphorus insecticide Dipterex are reported. Three to five weeks after insecticide ingestion signs of a distal sensorimotor (preponderantly motor) neuropathy occurred. The patients complained of paraesthesia in the lower limbs, and two of them of very disagreeable pricking sensation in the soles of the feet, responsive to carbamazepine. They showed distal weakness mainly of the legs, footdrop , difficult gait and muscle hypotonia. Ankle jerk was abolished while other tendon reflexes persisted. Two months or even later after poisoning, knee jerks in all the patients were very brisk and more and less accompanied by other pyramidal signs (patellar clonus, abolishment of abdominal cutaneous reflexes, Babinski's sign). Clinical, electrophysiological and nerve biopsy data revealed a "dying-back" neuropathy in our patients. Distal muscle fatigue was confirmed by failure of neuromuscular transmission on repetitive nerve stimulation.

Induction of electrophysiological and morphological changes in Sprague-Dawley rats fed tributoxyethyl phosphate

The effects of a widely used trialkyl phosphate (TP), tributoxyethyl phosphate (TBOP), on the peripheral nervous system of Sprague-dawley (SD) rats were investigated. Male and female SD rats were administered this chemical by gavage over a period of 18 weeks (low dose: 0.25 ml kg-1; high dose: 0.50 ml kg-1). Electrophysiological changes observed at 18 weeks in all test animals included a significant reduction (P less than 0.001) in nerve conduction velocity and an important increase (P less than 0.001) of both relative (RRP) and absolute refractory period (ARP). Light and electron microscopic examination of sciatic nerve from all test animals showed the presence of degenerating myelin sheaths accompanied by axonal swelling. An advanced stage of degeneration was indicated by the presence of lamellated electron dense inclusions in unmyelinated nerve fibres.

Time course effects of soman on acetylcholine and choline levels in six discrete areas of the rat brain

The time course of changes in rat brain levels of acetylcholine (ACh) and choline (Ch) was investigated following a single SC injection of soman (0.9 LD50, 120 micrograms/kg) to understand the relationship between central neurotransmitter alteration and soman toxicity. Of the animals exposed to the dose of soman, 46% died within 24 h, with maximum mortality occurring during the first 40 min following soman administration. In a second group, surviving rats were killed at various times after treatment by a beam of focused microwave radiation to the head, and ACh and Ch levels were determined by gas chromatography-mass spectrometry. Soman produced a maximal ACh elevation in the brain stem at 20 min (34.4%), in cerebellum at 40 min (51.9%), in cortex and striatum at 2 h (320.3% and 35.2%, respectively), and in hippocampus and midbrain at 3 h (94.5% and 56.8%, respectively). ACh levels remained above normal approximately 30 min in the brain stem; 2 h in the midbrain, cerebellum, and striatum; 8 h in the cortex; and 16 h in the hippocampus. Ch levels were elevated in all areas except the striatum. Ch maxima occurred at 10-40 min and returned to control levels approximately 3 h after injection. Results suggest that perturbation of ACh levels due to soman was not uniform throughout the brain and that soman toxicity may reflect ACh changes in multiple areas, rather than changes in any given area. These data further suggest a possible relationship between elevated Ch levels and soman toxicity.