Scientific Poster Session III - Case Reports

Case Reports
  Monday, November 13, 2023
  01:00 PM–02:30 PM

Abstract

Introduction: Elevated bromide levels can cause neurological abnormalities. There is a paucity of data describing bromide toxicity from high doses of pyridostigmine bromide (PB). This case describes a patient with an elevated level from a therapeutic dose of immediate release PB.

Case: A 37-year-old male with a type B2 thymoma status post thymectomy complicated by myasthenia gravis presented in myasthenic crisis with dysphagia, difficulty breathing, and neck flexion weakness. He required mechanical ventilation for seven days and was treated with intravenous immunoglobulin, steroids, PB and subsequent plasmapheresis. On day nine he experienced acute agitation. He was physically and verbally aggressive. The patient had a low anion gap=2 mEq/L, chloride=109 mEq/L, and albumin=4.5 g/dL. All other laboratory values were normal. The daily dose of PB was 660 mg and bromide toxicity was high on the differential. On day 10 his bromide level was 37 mg/L (normal<0.5 mg/L), drawn 4-hours after a 90 mg dose. His agitation was initially managed with quetiapine followed by PB dose reduction to 360 mg/day.

Discussion: To our knowledge there are two cases of bromide toxicity secondary to PB. These patients experienced agitation, confusion, paranoid delusions, visual hallucinations, and coma with levels of 88–90 mg/L (toxic levels>50–100 mg/dL). The NMS Labs reports concentrations >12 mg/L increases the risk of electroencephalogram disturbances. While our patient’s bromide level was not as high as those previously reported, there was no other obvious cause of his agitation. We did not obtain a repeat bromide level on the lower PB dose which is a limitation. Hyperchloremia, a low or negative anion gap, or acute neurological changes while on PB warrants obtaining a bromide level and consideration of lowering the PB dose.

Conclusion: Elevated bromide levels from therapeutic PB can occur and monitoring of levels should be considered.

Presenting Author

Aubrey Defayette PharmD
Roswell Park Comprehensive Cancer Center

Authors

Ajay Abad MD
Roswell Park Comprehensive Cancer Center

Elizabeth Anibaldi PA
Roswell Park Comprehensive Cancer Center

Chinazom Ibegbu MD
Roswell Park Comprehensive Cancer Center

Ravi Doobay MD, FRCPC
Roswell Park Comprehensive Cancer Center

Nicholas Silvestri MD
University at Buffalo Jacobs School of Medicine and Biomedical Sciences