chorea may be the manifestation of a wide variety of degenerative , vascular , metabolic , or toxic disorders involving the central nervous system , in which dysfunction of the basal ganglia , particularly of the striatum , is generally assumed to be responsible .
we report an index case of generalized chorea secondary to the ingestion of propiconazole toxin ( fungicide ) in a young female . in this case ,
the patient was a 35-year - old lady who was a known case of primary juvenile myoclonic epilepsy , on treatment with valproate ( 800 mg / day ) for 7 years .
she was found in unconscious state at home by the family , who then took her to the emergency department of another facility . in view of prior history of epilepsy ,
three days later , due to persistent unresponsive neurological condition , she was referred to our tertiary care hospital for further management . at admission ,
her glasgow coma scale was e2m5v1 , with bilateral small - sized pupils ( 2 mm , reacting ) , heart rate of 64/min , blood pressure 90/60 mmhg on inotropic support with norepinephrine 2 g / kg / min and dopamine 8 g / kg / min .
blood biochemistry and metabolic profile were normal with total leukocyte count-12,000/mm , rbs-85 mg / dl , blood and urine culture were sterile .
electroencephalogram was done to rule out status epilepticus while the patient was on valproate ( blood level-80 ) and no sedatives .
magnetic resonance imaging ( mri ) brain with contrast , and cytological and biochemical analysis of cerebrospinal fluid were normal . on day 3 of her illness when inotropes had been tapered , her heart rate was in the range of 5058/min .
bradycardia ( even with inotropic support ) along with small - sized pupils raised the suspicion of intoxication .
furthermore , relatives were redirected to look for any evidence of suspicious compound at home .
cholinesterase levels were very low ( 134 ) along with an empty bottle of propiconazole toxin ( fungicide ) found at home , confirming the diagnosis of intoxication .
however , on the 9 day of her illness , she developed irregular random flowing movements from one part of the body to another , suggesting generalized chorea [ video 1 ] .
a detailed family history was not positive for any chorea / choreiform movements suggestive of inherited degenerative disorders .
the patient was extensively evaluated for other acquired cause of chorea , but her hematological investigations including peripheral blood film , biochemical , thyroid function , serum valproate levels , and vasculitic workup were negative and repeat mri brain and computed tomography ct abdomen were also normal . she was treated with clonazepam ( 2 mg ) , tetrabenazine ( 75 mg ) , and risperidone ( 2 mg ) with partial improvement in chorea .
our case depicts initial diagnostic dilemma , which is frequent problem in intoxication as history is often concealed .
hence , insecticide poisonings are relatively a common occurrence with wide spectrum of neurological presentations which may affect the function of the central and peripheral nervous system .
clinical manifestations vary greatly , and include movement disorders such as secondary parkinsonism and a wide range of hyperkinetic disorders and even delayed neuropathy .
propiconazole is the triazole class of fungicide and is available as an emulsifiable concentrate ready - to - use liquid [ figure 1 ] .
it is also known as dmi or demethylation - inhibiting fungicide , due to its binding with and inhibition of 14-alpha - demethylase enzyme . to the best of our knowledge ,
this is the index case of generalized chorea following intoxication with propiconazole ( fungicide ) .
the probable mechanism may be excessive acetylcholine activity in the nigrostriatal system due to inactivation of acetylcholinesterase by propiconazole . within the nigrostriatal network , caudate nucleus and
globus pallidus are particularly rich in cholinergic neurons causing less inhibition of pallidothalamic fibers and generalized choreiform movements .
chemical structure of propiconazole ( c15h17cl2n3o2 ) the neurological manifestation with propiconazole intoxication is not reported in literature
. only few cases of extrapyramidal manifestations following cholinergic intoxication secondary to organophosphate poisoning ( opc ) have been described . in the three cases described by joubert et al . , the extrapyramidal manifestations were limited to choreiform movements .
although exact mechanism of action of propiconazole is not clear , but circumstantial evidence , low cholinesterase levels , and response to anticholinergic treatment sufficiently support our diagnosis . with
delayed development of generalized chorea as neurological sequelae , propiconazole may be added as another compound in the causal list of toxic chorea widening the spectrum of acquired toxic causes of chorea still further . in a country like ours , where poisonings are frequent exposure to toxic agents
 chorea is a rare manifestation of poisoning . 
 we report an index case of a young woman who developed generalized chorea following propiconazole toxin ingestion . as large series on neurological complications of toxic compounds are difficult to be compiled , it is of interest to report our experience . 
 this report adds one more compound to the increasing list of toxic chorea . 
Introduction
Case Report
Discussion
Conclusion
Video available on: 
Financial support and sponsorship
Conflicts of interest