C53-47 Status Epilepticus Following Ingestion of a Household Insecticide Spray Containing Synthetic Pyrethroids

Introduction Pyrethroids, synthetic analogues of pyrethrin, used in household and agricultural insecticides, are generally considered less toxic to human. Most poisonings are accidental, but intentional ingestion for self-harm poses a growing concern. At high doses, these agents can cross the blood-brain barrier causing neurotoxic effects like irritability, encephalopathy, muscle fasciculations, seizures but status epilepticus and shock are rarely reported. We present a case of status epilepticus and multi-organ dysfunction after ingestion of a pyrethroid-based insecticide spray. Case Presentation A 61-year-old male with a history of crack cocaine use, emphysema, and mood disorder was brought to the emergency department after being found unresponsive with generalized shaking movement following reported intentional insecticide ingestion. On arrival, he was unconscious (GCS 3), diaphoretic, and had dilated pupils. Intranasal naloxone was administered. He was intubated for airway protection and started on norepinephrine and vasopressin for hypotension. Later, he developed multiple episodes of seizure-like activity without improvement in mental status concerning for status epilepticus. He received midazolam boluses followed by a continuous infusion. Levetiracetam was also started as a second agent. Activated charcoal was also administered. Ceribell EEG demonstrated two electrographic seizures one hour apart. Laboratory studies showed severe lactic acidosis (pH 7.03, lactate 16.1 mmol/L), leukocytosis, transaminitis, and acute kidney injury (creatinine 1.9). Toxin screen was positive for cocaine. Presentation was consistent with possible synthetic pyrethroid toxicity. MRI of the brain revealed no structural abnormality. Infectious work-up was unremarkable. After 24 hours of symptomatic treatment with benzodiazepines, his mental status, lactic acidosis and kidney function significantly improved. He was successfully extubated, and he confirmed the self harm attempt with household insecticide. Antiepileptics were transitioned to lacosamide due to suicidal thoughts and later discontinued as outpatient. Discussion and Clinical Importance This case highlights the severe, life-threatening toxicity of pyrethroid inhalation or ingestion. While most exposures lead to mild symptoms, rarely, multiorgan dysfunction and severe neurotoxicity can occur, particularly in large, intentional exposures. The management is supportive, with benzodiazepines as first-line therapy and phenobarbital for refractory seizures. Levetiracetam may serve as a second-line agent. Recovery is typically observed within 12-24 hours after the compound is metabolized. Notably, status epilepticus and hypotension are extremely rare in pyrethroid toxicity, with very limited literature documenting these atypical complications. Hence. We highlight the need for considering pyrethroid toxicity in patients with unexplained seizures and hypotension, especially following exposure to aerosolized insecticides ingestion.