Potentially life-threatening emergency
Cholinergic syndrome
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Synopsis

Cholinergic syndrome is a toxidrome, or a set of symptoms associated with poisoning from certain substances. Symptoms are predominantly caused by activation of muscarinic receptors that control the parasympathetic nervous system.
Symptoms include bradycardia, wheezing, diaphoresis, miosis, diarrhea, and salivation. Activation of nicotinic acetylcholine receptors can also cause hypertension. Muscarinic effects result from parasympathetic overstimulation (miosis and blurred vision; excessive secretions, especially salivation, lacrimation, urination, defecation, gastric cramping, and emesis [SLUDGE]).
Drugs that can induce cholinergic syndrome include organophosphates (insecticides), carbamates, cholinergic drugs such as physostigmine, and nicotine. Cholinergic syndrome can be life threatening.
Treatment is with anticholinergic drugs, such as atropine. Pralidoxime is additionally used in cases of organophosphate poisoning.
Symptoms include bradycardia, wheezing, diaphoresis, miosis, diarrhea, and salivation. Activation of nicotinic acetylcholine receptors can also cause hypertension. Muscarinic effects result from parasympathetic overstimulation (miosis and blurred vision; excessive secretions, especially salivation, lacrimation, urination, defecation, gastric cramping, and emesis [SLUDGE]).
Drugs that can induce cholinergic syndrome include organophosphates (insecticides), carbamates, cholinergic drugs such as physostigmine, and nicotine. Cholinergic syndrome can be life threatening.
Treatment is with anticholinergic drugs, such as atropine. Pralidoxime is additionally used in cases of organophosphate poisoning.
Codes
ICD10CM:
T44.1X4A – Poisoning by other parasympathomimetics [cholinergics], undetermined, initial encounter
SNOMEDCT:
61356009 – Poisoning by parasympathomimetic drug
T44.1X4A – Poisoning by other parasympathomimetics [cholinergics], undetermined, initial encounter
SNOMEDCT:
61356009 – Poisoning by parasympathomimetic drug
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Diagnostic Pearls
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Differential Diagnosis & Pitfalls
- Asthma
- Anaphylaxis
- Seizure
- Alcohol withdrawal
- Anticholinergic toxicity
- Neuroleptic malignant syndrome
- Serotonin syndrome
- Opioid or sedative / hypnotic withdrawal
- Drug side effects (eg, cocaine, amphetamine, MDMA, nicotine, salicylates, pyridostigmine)
- Myasthenia gravis
- Lambert-Eaton syndrome
- Toxic mushroom ingestion
- Psychiatric disorder
- Viral upper respiratory tract infection
- Influenza
- Gastroenteritis
- Inflammatory bowel disease (eg, Crohn disease, ulcerative colitis)
- Irritable bowel syndrome
- Allergic rhinitis
- Vasomotor rhinitis
- Hypoglycemia
- Diabetic ketoacidosis
- Adrenal crisis
- Hyperthyroidism / thyrotoxicosis
- Electrolyte disturbance (eg, hypomagnesemia, hypophosphatemia)
- Guillain-Barré syndrome
- Botulism
- Sepsis
- Thrombotic thrombocytopenic purpura / hemolytic uremic syndrome
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Therapy
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Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.
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References
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Last Reviewed:03/06/2019
Last Updated:11/07/2019
Last Updated:11/07/2019