Acute Anticholinergic Toxic Syndrome Due to Scopolamine Exposure: A Case Report with Possible Drug-Facilitated Administration.

INTRODUCTION

Scopolamine is a tropane alkaloid and non-selective muscarinic receptor antagonist capable of inducing a central anticholinergic toxidrome with pronounced neuropsychiatric and autonomic manifestations. Despite its well-characterized pharmacology, diagnosis remains clinically challenging due to variable presentation and often absent or unreliable exposure history, particularly in non-medical contexts.

METHODS

We report a case of a 34-year-old female presenting with an acute onset of altered mental status following a social event. Clinical findings included delirium, hallucinations, psychomotor agitation, dysarthria, bilateral mydriasis with preserved light reflex, sinus tachycardia, and marked urinary retention. Routine laboratory investigations were largely within normal limits, and standard urine toxicology screening was negative except for iatrogenic benzodiazepines. Given the characteristic toxidrome, extended toxicological analysis using gas chromatography-mass spectrometry (GC-MS) was performed, confirming the presence of scopolamine. Supportive treatment, including benzodiazepines and off-label intravenous galantamine, was administered, resulting in progressive clinical improvement and complete recovery without sequelae.

RESULTS

This case underscores the diagnostic limitations of routine toxicology screening for tropane alkaloids and highlights the importance of a pattern-based toxidrome approach. Given the absence of reliable exposure history and the presence of marked anterograde amnesia, an exogenous exposure cannot be excluded; however, no direct forensic evidence supports intentional administration. Furthermore, galantamine may represent a pharmacologically plausible alternative to physostigmine in settings where it is unavailable, although evidence remains limited.

CONCLUSIONS

Scopolamine intoxication should be considered in cases of acute anticholinergic syndrome with negative standard screening, and confirmation requires advanced analytical methods such as GC-MS.