A case of rivastigmine toxicity caused by transdermal patch

Rivastigmine is a carbamate cholinesterase inhibitor used in the treatment of dementia. Toxicity is expected to resemble poisoning from other carbamates and organophosphates with features of both muscarinic (salivation, lacrimation, urination, defecation, miosis, bronchorrhea, and bradycardia) and nicotinic (muscle weakness, fasciculations, and paralysis) stimulation. We present a case of rivastigmine toxicity caused by transdermal patch. After removal of patches, the patient's symptoms and signs were spontaneous recovery without atropine and oxime therapy. Emergency physicians should be aware of the signs of increased nicotinic, muscarinic, and central nervous system effects (seizure), which are the same as with organophosphate and carbamate toxicities, and strongly consider carbamate cholinesterase inhibitor (rivastigmine) overdose.