Initial reflex syndrome

Diller describes three main phases associated with phosgene induced lung injury as the initial reflex syndrome, the clinical latent phase and the clinical oedema phase. ... 

In cases of attempted suicide, often fatal intoxications occur where, in spite of early hospitalization, patients are beyond remedy. Initially, signs of recovery may be observed, but after 2-3 days patients relapse with a measurable increase in OP plasma concentrations. This phenomenon is called intermediary syndrome (IMS), first described by Senananyake et al. in 1987, and is possibly a consequence of a severe intoxication with permanent depolarization of the neuromuscular end-plates and constant excitation of the nicotinic acetylcholine receptors in the CNS of the patient. The IMS is clinically characterized by acute respiratory paresis, weakness of facial, palatal, external ocular, nuchal and proximal limb muscles and depressed tendon reflexes. Some authors propose that an insufficient therapy with oximes or atropine (see Section 9.2.5) and inadequate artificial respiration in the early stages of intoxication may cause the occurrence of an IMS. It is further remarkable that only some distinct OP agents (e.g. fenthion, dimethoate, monocrotophos and methamidophos) seem capable of producing the IMS. 

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