Neuropathy due to phytosol (agritox). Report of a case

Cu2+-dependent stereoselective hydrolysis of a chiral organophosphonothioate insecticide for domestic mammals' sera and its albumins

Acute toxicity of organophosphate (OPs) pesticides is a public health problem. The adverse effects are associated with the inhibition and aging of nervous system B-esterases such as acetyl cholinesterase (AChE) and neuropathic target esterase (NTE). Treatment based on A-esterases such as mammal serum paraoxonase-1 has been suggested. This ex vivo study shows the Cu²⁺-dependent hydrolysis of trichloronate (TCN), a racemic organophosphonothioate insecticide, in human and domestic mammal serum (dog, goat, pig, sheep and cow). Ca²⁺-dependent (2.5 mM) or EDTA-resistant (5 mM) activity (1-6%) was not significant (p>0.05) in all samples, except goat serum and its albumin, which showed higher levels of TCN hydrolysis (38-58%) than other mammals with 100 and 300 μM copper sulfate at physiological conditions for 60 min. Goat serum albumin (GSA) showed significant (p˂0.05) stereoselective hydrolysis (+)-TCN ˃ (-)-TCN (45% versus 33%). This suggests that GSA is the protein responsible for Cu²⁺-dependent TCNase activity in goat serum. This is the first report on Cu²⁺-dependent A-esterase activity in mammalian tissues. This goat serum cuproprotein could be considered as an alternative in future biotechnological applications including enantiomeric synthesis, bioremediation and antidotal treatment of organophosphonothioate pesticide poisoning.

Pesticide-Related Incidents Treated in Finnish Hospitals - A Review of Cases Registered Over a 5-Year Period

Pesticide-related incidents are uncommon in Finland. They comprised 0.11% of all hospitalizations due to poisoning in 1987-88. A search of the nationwide Hospital Discharge Register revealed 78 pesticide-related incidents in a 5-year period. Some 30 different agents were involved, the most frequent being organophosphate and MCPA. Only 36 cases (46%) were judged to be unequivocal or probable pesticide poisonings; 26 (33%) were probably other illnesses because of no or minimal exposure and of the children admitted for follow-up, nine (12%) had potentially marked exposure, but no poisoning developed owing to vigorous early treatment which limited absorption, and seven (9%) cases remained undetermined. According to our analysis, the management of patients with (suspected) pesticide poisoning at hospitals could be further improved if the following procedures were emphasised: decontamination of the skin when appropriate, systematic early estimation of the likely dose involved, analytical verification of pesticide absorption whenever feasible, and consistent collaboration with a toxicological advisory service.

Axonal degeneration with unusual lesions of the myelin in an occupational neuropathy

A 35-year-old man had prolonged occupational exposure to lead carboxylate, triethylbenzene, xylene, and dichloromethane, when he developed a subacute predominantly sensory neuropathy. Ultrastructural examination of a peripheral nerve biopsy showed axonal degeneration and unusual lesions of the myelin, with Schwann cell sequestration of vesicular and lamellar debris. Biochemical analysis of lead in a frozen peripheral nerve specimen revealed no significant difference between the propositus and a control. The authors were unable to find any similar peripheral nerve lesions in the literature dealing with neurotoxic chemicals. Any of the several organic solvents could have equally caused the neuropathy and may have been potentialized by the other chemicals.

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.

Low-level exposures to organophosphorus esters and peripheral nerve function

This review evaluates the epidemiological and clinical evidence linking low-level and prolonged exposures to organophosphorus esters, used as insecticides or nerve agents, to peripheral nerve dysfunction. The clinical effects of large doses of these chemicals-including the cholinergic syndrome, the intermediate syndrome, and the delayed polyneuropathy-are all well established and are summarized. Based on these clinical observations and experimental studies, dose-effect relationships indicate that peripheral neuropathy always develops after cholinergic toxicity. However, several studies have suggested that this relationship may be different after low-level prolonged exposures, as, for instance, those experienced by Gulf War veterans and British sheep farmers, thereby leading to the development of peripheral neuropathy without preceding cholinergic toxicity. A critical assessment of these studies, involving subjects with either current or past exposures, indicates that changes in peripheral nerve function were mild, inconsistent, and unexplained and that most studies lack exposure data. Suggestions made about individual hypersusceptibility to delayed polyneuropathy lack support. It is concluded that there is no evidence of peripheral nerve dysfunction caused by low-level prolonged exposures to organophosphate insecticides or nerve agents.

Onset of grip- and pinch-strength impairment after acute poisonings with organophosphate insecticides

The course of organophosphate-induced delayed polyneuropathy (OPIDP) in humans has not been quantitatively measured in epidemiologic studies. This study evaluated the association of acute OP poisonings with motor neurologic impairment. Hand grip and pinch strength were evaluated among 62 Nicaraguan men hospitalized for acute OP poisoning between 1992 and 1996; 39 cattle ranchers and fishermen who had never experienced pesticide poisoning were controls. Exposure categories were moderate and severe poisonings with neuropathic and non-neuropathic OPs. Strength was measured at hospital discharge and seven weeks after poisoning. Grip and pinch strength were impaired among all OP-poisoned subjects at both examinations, more noticeably among those poisoned with OPs with suspected neuropathic effects, methamidophos and chlorpyrifos. In those with severe poisonings with neuropathic OPs, impairments were more marked among intentional than among occupational poisonings. The performances of suicidal subjects worsened at the second examination, consistent with OPIDP. Early motor impairment at the time of hospital discharge is consistent with cholinergic depolarization blockade after acute poisoning. The persistence of deficits in motor strength in all severely poisoned patients regardless of pesticide type was unexpected, and may reflect persistent cholinergic blockade or intermediate syndrome, neuropathy, or a combination of these.

Clinical, biochemical and neurobehavioural studies of workers engaged in the manufacture of quinalphos

59 workers exposed to different chemicals during the manufacture of quinalphos, an organophosphate pesticide (OP) and 17 control subjects were studied. Despite similar blood acetylcholinestarase (AChE) levels in both the exposed and control subjects, a significant number of exposed subjects had altered plantar and ankle reflexes. Higher nervous functions such as memory, learning and vigilance were also found to be affected in these subjects. These findings were attributed to chronic low dose combined exposure to different chemicals used/formed in the manufacture of quinalphos. The study raises the doubt that monitoring of AChE alone among subjects engaged in the manufacture of OP pesticides may not be an adequate safeguard as regards to their health.

Biochemical, neuropathological and behavioral studies in hens induced by acute exposure of tri-ortho-cresyl phosphate

A "hen model" or organophosphorus induced delayed neuropathy (OPIDN) has been developed using white leghorn exposed acutely to one of five dosages of tri-ortho-cresyl phosphate (TOCP), between 300 to 700 mg/Kg. Neuropathy target esterase was studied in brain and peripheral nerve 24 and 48 hrs following exposure. Behavioral symptoms abnormality was assessed from days 1 through 20 after exposure using a 7 point rating scale and neuropathological examination was conducted on sample collected from animals on days 0, 7, 14 and 21. Neuropathological abnormalities were indicated by damage scores between 0 (no damage) and 4 (gliosis of brain tissue, myelin loss, appearance of axonal foci etc and more than 55% degeneration of peripheral nerve fibres). TOCP (600 and 700 mg/Kg, orally) was able to inhibit NTE more than 75% in brain and peripheral nerves. TOCP at the same dosage was also capable of resulting maximal levels of neuropathological score at 4. After exposure to doses weight loss was observed abruptly in a greater extent at the beginning leading to a change in weight gain till the end of the experiment. Behavioral signs were also dose dependent. Symptoms (gain abnormality, ataxia, paresis) were noted on the early stage of experiment. Inhibition of NTE was 65% could not be reached in hens given TOCP without causing lethality and no significant ataxia or lesions developed in those birds. Behavioral signs were also observed to be late onset. These data indicate that more than 75% inhibition of peripheral nerve NTE after 24 hr exposure was predictive of severe behavioral abnormalities and pathology in the hen whereas less peripheral NTE inhibition was indicative of less severe behavioral abnormalities and a lower score for neuropathological damage.

Elevated quantitative vibrotactile threshold among workers previously poisoned with methamidophos and other organophosphate pesticides

To evaluate chronic effects of acute organophosphate pesticide poisoning, quantitatively determined vibrotactile thresholds were measured as an index of peripheral neuropathy among agricultural workers in Nicaragua. Thirty-six male workers were evaluated between 10 and 34 months after hospitalization for acute organophosphate poisoning and compared to an age- and sex-matched community reference group. Vibrotactile thresholds were measured quantitatively in right and left index fingers and right and left great toes. Study subjects were stratified into three groups: 1) never poisoned; 2) poisoned with organophosphates other than methamidophos, agents which have not been reported to cause peripheral neuropathy; and 3) poisoned with methamidophos, a peripheral neurotoxin. For all digits, there was a statistically significant trend of increasing age- and height-adjusted thresholds across these three exposure categories. Over one fourth of patients previously poisoned with methamidophos we studied had abnormal vibrotactile thresholds. These results suggest that previously reported cases of organophosphate-induced delayed polyneuropathy may represent only the worst disease in a spectrum of impairment, a sequela of exposure that may be much more common than previously thought.

Neurological aspects of organophosphate poisoning

Besides their well-known anticholinesterase action resulting in a typical acute cholinergic crisis, organophosphorus (OP) agents are capable of producing several subacute or chronic neurological syndromes. The acute over-stimulation at the neuromuscular junction results in muscle fiber necrosis. The significance of this OP-induced myopathy in human intoxication is unknown. Organophosphate-induced delayed neuropathy (OPIDN) arises 1-3 weeks after exposure to some OP compounds all capable of remarkably inhibiting a distinct esterase called neuropathy target esterase (NTE) during a critical time period. An experimental hen model has been designed to screen new OP compounds as to their delayed neurotoxic effects. The recently described intermediate syndrome emerges 1-4 days after an apparently well-treated cholinergic crisis. It main clinical features are sudden respiratory paralysis, cranial motor nerve palsies, and proximal limb muscle and neck flexor weakness. Whether or not this is a separate entity in OP agent toxicology remains to be seen. Further studies are required to further determine its clinical and paraclinical characteristics and the actual type of underlying neuromuscular dysfunction involved.

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.

Inhibition of lymphocytic neuropathy target esterase predicts the development of organophosphate-induced delayed polyneuropathy

Neuropathy Target Esterase (NTE) is the molecular target in the nervous system for organophosphorus esters (OP) when they cause delayed polyneuropathy. Some NTE activity was recently found also in blood lymphocytes. An unsuccessful suicide attempt with the widely used pesticide chlorpyrifos (0,0-diethyl-0-3,5,6,-trichloro-2-pyridyl phosphorothioate) is reported, where prior inhibition of lymphocytic NTE correlates with the delayed development of polyneuropathy. A 42-year-old man drank approximately 300 mg/kg chlorpyrifos. The subsequent severe cholinergic syndrome lasted for 17 days with varying degrees of severity. Thirty days after intoxication the clinical and electrophysiological examination of the peripheral nervous system was normal but lymphocytic NTE was about 60% inhibited. On day 43 the patient began to complain of paresthesia and leg weakness. Clinical examination, electrophysiology and a nerve biopsy revealed signs of a peripheral polyneuropathy, axonal in type. This case report indicates that measurement of lymphocytic NTE might be used as a clinical test to predict the development of OP-induced delayed polyneuropathy.

Biological monitoring for organophosphate-induced delayed polyneuropathy

Certain organophosphate (OP) pesticides cause a delayed polyneuropathy. The two-step initiation mechanism for this toxicity involves the phosphorylation and subsequent 'aging' of a protein in the nervous system called Neuropathy Target Esterase (NTE). The observation of this enzyme activity in peripheral blood lymphocytes led to several studies to verify whether its measurement after OP exposures might be used as a biological monitoring test for the OP-induced delayed polyneuropathy (OPIDP). The evidence, so far, on the use of this biochemical test in man is discussed together with the need for further research.

Neuropathy target esterase in human lymphocytes

Measurement of neuropathy target esterase activity (NTE) in blood lymphocytes has been suggested as a possible biomonitor for organophosphate-induced delayed polyneuropathy. Human lymphocyte NTE was characterized in vitro according to the sensitivity to several organophosphate inhibitors, which was found similar to that of the nervous system enzyme. Methods for collection, storage, and processing of blood and the NTE assay are described (averaged coefficient of variation of the method is 8%). The mean (+/- SD) value of lymphocyte NTE activity in a caucasian population (108 healthy subjects) was 11.5 +/- 2.5 nMoles/min X mg of protein. No sex or age differences were detected. The averaged intraindividual coefficient of variation was 10.1%. These results suggest the feasibility of the test in clinical conditions, a sufficient reproducibility of the test, and a large interindividual variation. Appropriate baseline values are advisable when using the test to evaluate the effects of an occupational exposure to organophosphorus esters which may cause delayed polyneuropathy.

Enzyme studies with human and hen autopsy tissue suggest omethoate does not cause delayed neuropathy in man

Levels of acetylcholinesterase and neurotoxic esterase were measured in brain autopsy material. In tissue from a fatal human poisoning and from hens given 4-8 x unprotected LD50 AChE was highly inhibited and neurotoxic esterase uninhibited. The findings correlate with the inhibitory power of omethoate against these enzymes in vitro. It is concluded that omethoate has negligible potential to cause delayed neuropathy and a published report of human neuropathy due to omethoate is criticised.