[Acute respiratory failure associated with cholinergic crisis: report of five cases and review of the literature].

Distigmine bromide is a cholinesterase inhibitor widely used for the treatment of hypotonic neurogenic bladder. However, this drug is also known to cause cholinergic crisis, a rare but serious adverse reaction. Cholinergic crisis is an excessive amount of acetylcholine due to the systemic inhibition of cholinesterase activity, characterized by parasympathetic symptoms such as sweating, salivation, miosis, bradycardia, diarrhea and circulatory and respiratory failure. The incidence of cholinergic crisis has been estimated at approximately 0.2%, and the majority of the patients are elderly with underlying conditions such as cerebrovascular disease. Since 2004, we have encountered 5 cases of acute respiratory failure associated with cholinergic crisis induced by the administration of a normal oral dose of distigmine. We present these cases here and review an additional 23 cases from the literature in Japan. In these 28 cases, mechanical ventilation was required for 57%, with a mean duration of 5.1 days and a mortality rate of 11%. Pneumonia was observed in half of the cases in the acute phase, and relapse due to the readministration of distigmine was reported in 20% of cases. It is important to remember that cholinergic crisis in the elderly is often misdiagnosed and is occasionally treated as simple aspiration pneumonia.

Successful chemotherapy for small-cell lung cancer in an elderly patient undergoing continuous ambulatory peritoneal dialysis.

A standard treatment has not yet been established for elderly small-cell lung cancer patients, especially when they have end-stage renal disease. We report the first case of successful chemoradiotherapy in an elderly small-cell lung cancer patient undergoing continuous ambulatory peritoneal dialysis. A 77-year-old Japanese man on continuous ambulatory peritoneal dialysis was diagnosed as having limited disease small-cell lung cancer. He received four monthly cycles of chemotherapy consisting of carboplatin at 240 mg/m(2) on day 1 and etoposide at 40 mg/m(2) on days 1 and 3. He underwent additional hemodialysis on days 1 and 3, while continuous ambulatory peritoneal dialysis continued as usual on the other days. Following chemotherapy, he underwent hyperfractionated radiotherapy to a total dose of 45 Grey, resulting in complete remission of the disease. A pharmacokinetic study showed an area under the concentration-time curve of carboplatin of 3.41 to 4.88 mg.min/mL, increasing gradually over the first three cycles, while etoposide did not show this gradual increase. The increased area under the concentration-time curve of carboplatin may have reflected a worsened renal function during chemotherapy. Despite dose reductions and favorable areas under the concentration-ime curve of carboplatin, the patient suffered grade 3-4 hematological toxicities, necessitating transfusions and a further dose reduction. The patient died of recurrent small-cell lung cancer 19 months after diagnosis.