Initially synthesized by humans as a weapon for chemical warfare, sarin (also known as O-isopropyl methylphosphonofluoridate) is a colorless and clear liquid that belongs to a group of highly toxic and life-threatening nerve agents [1] [2]. Similar to organophosphates, sarin behaves as an inhibitor of acetylcholinesterase (Ach); thus it produces symptoms by promoting cholinergic effects at both muscarinic (M) and nicotinic (N) receptors of the parasympathetic part of the autonomic nervous system [2] [3] [4] [5]. Sarin poisoning has been described in very few reports, mainly during the terrorist attacks in Japan during the 90's [1] [3] [6]. In addition to direct contact with its liquid form, individuals can inhale sarin as a gas and it is equally potent in both forms [2]. The clinical presentation depends on the route of exposure - dermal absorption may delay first signs for up to 18 hours, with local sweating and glandular hypersecretion, together with weakness and fasciculations being the main symptoms [2] [4]. On the other hand, instantaneous development of life-threatening symptoms such as airway obstruction, weakness and failure of respiratory muscles leading to anoxia, and convulsions is seen in the case of inhalation [2] [4]. Additional findings include miosis, hypothermia, muscle twitching, tremors, ataxia, visual deficits, cardiac abnormalities (including cardiac arrest) and coma [1] [3] [7].

• Intravenous Administration

  Intravenous administration of atropine sulfate to mildly ill victims was adverse. We believe that it was because eye symptoms were mainly due to local reaction of sarin. [nointervention.com]

  In more severe cases, intravenous administration must be used. Diazepam should be administered in repeated i.m. or i.v. doses (10–15 mg or 0.2 mg/kg for children). [academic.oup.com]

• Asymptomatic

  These findings suggest that asymptomatic sequelae to sarin exposure, rather than PTSD, persist in the higher and visual nervous systems beyond the turnover period of ChE; sarin may have neurotoxic actions in addition to the inhibitory action on brain [ncbi.nlm.nih.gov]

• Virilization

  Some of his best selling popular science books include: Better Looking, Better Living, Better Loving, (2007), Elements of Murder (2005), Vanity, Vitality & Virility (2004), Nature's Building Blocks (2001), The Shocking History of Phosphorus (2000), Molecules [books.google.de]

• Sore Throat

  The symptoms of exposure included ocular pain, darkness of visual field, nausea, vomiting, headache, rhinorrhea, narrowing of visual field, sore throat, fatigue, and dyspnoea, which were similar to those reported by the citizens who were sarin victims [ncbi.nlm.nih.gov]

  Patients complained of darkness, visual blurring, ocular pain, hyperemia and miosis in addition to systemic symptoms as running nose, nausea, headache and sore throat. [webview.isho.jp]

  Over 20% of house staff who treated victims had symptoms that included ocular pain, headache, sore throat, dyspnea, nausea, dizziness, and nose pain, but none was seriously affected ( Fig 4 ). [nointervention.com]

  Early symptoms include sinus congestion, a sore throat, and hoarseness. Later, cough, shortness of breath, and trouble breathing may develop. [emedicinehealth.com]

• Bronchorrhea

  Intubation may be necessary in cases of respiratory distress due to laryngospasm, bronchospasm, bronchorrhea, or seizures. Immediate aggressive use of atropine may eliminate the need for intubation. [openanesthesia.org]

• Abdominal Cramps

  Symptoms like bronchoconstriction, nausea and vomiting, abdominal cramps and diarrhoea may also diminish. Atropine will also reduce the parasympathetic overstimulation and the consequent risk of bradyarrhythmias induced by ACh accumulation. [academic.oup.com]

  Symptoms include: Dilated pupils Headache Sense of pressure Salivation Runny nose or congestion Nausea Vomiting Tightness in chest Anxiety Mental confusion Nightmares Weakness Tremors or twitches Involuntary defecation or urination Abdominal cramps Diarrhea [thoughtco.com]

  Atropine also blocks other effects of poisoning, such as nausea, vomiting, abdominal cramping, low heart rate, and sweating. Atropine, however, does not prevent or reverse paralysis. [emedicinehealth.com]

• Foaming at the Mouth

  According to the Syrian Observatory for Human Rights (SOHR), victims were having difficulty breathing, foaming at the mouth, seizures, bleeding from the nose and mouth, fainting, and some progressed to losing consciousness and dying. [gcnlive.com]

  Excessive acetylcholine corroborates what has been reported and seen in the videos taken just after the attack, including uncontrolled salivation that will cause "foaming at the mouth," vomiting, tearing, involuntary defecation and urination, tiny pinpoint [tonic.vice.com]

  “For example, if it’s a secretion in the mouth, it will make the person foam at the mouth,” he said. If it’s tear ducts, it will make you cry. if its muscles in the leg, it will make the muscles twitch.” [pbs.org]

  Symptoms included bleeding from the nose and mouth, coma, convulsions, difficulty breathing, extreme sensitivity to light, flulike symptoms, foaming at the mouth, fevers, loss of consciousness, loss of memory, loss of vision, nausea, vomiting, paralysis [wired.com]

  Those on the periphery of that zone were the ones being rushed to hospitals, gasping for breath and foaming at the mouth, in the hopes of being saved. [foxnews.com]

• Formication

  Solvent A (0.2% v/v formic acid in water) and solvent B (0.2% v/v formic acid in acetonitrile) were used in gradient mode as follows: time (min)/B (%) 0/0 and 30/45 with a flow at 80 µL/min. [link.springer.com]

• Psychiatric Symptoms

  The results suggested delayed effects on psychomotor performance, the higher and visual nervous system and the vestibulo-cerebellar system with psychiatric symptoms resulting from PTSD. [ncbi.nlm.nih.gov]

• Anger

  fatigue, tension-anxiety, depression, and anger-hostility)-together with the paired-associate learning test-were associated significantly with posttraumatic stress disorder. [ncbi.nlm.nih.gov]

• Ataxia

  Additional findings include miosis, hypothermia, muscle twitching, tremors, ataxia, visual deficits, cardiac abnormalities (including cardiac arrest) and coma. [symptoma.com]

Except for terrorist attack-related incidents, the diagnosis of sarin poisoning has virtually never been made in general practice. Nevertheless, nerve agents such as sarin must be considered in the differential diagnosis of sudden and life-threatening respiratory and gastrointestinal tract complaints in a cluster of patients who were in the same surroundings shortly before symptoms occurred. For this reason, history taking that reveals many individuals affected by the same symptoms might be crucial in raising suspicion. Physicians must perform a quick physical examination during which cholinergic effects of sarin poisoning must be observed - miosis, sweating, hypothermia, muscle weakness, spasms, etc. In addition, some studies have identified leukocytosis, elevated serum creatine kinase levels, hyperglycemia, hypokalemia, and hypotriglyceridemia in the laboratory workup [3].

1. Abu-Qare AW, Abou-Donia MB. Sarin: health effects, metabolism, and methods of analysis. Food Chem Toxicol. 2002;40(10):1327-1333.
2. Lee EC. Clinical manifestations of sarin nerve gas exposure. JAMA. 2003;290(5):659-662.
3. Yanagisawa N, Morita H, Nakajima T. Sarin experiences in Japan: acute toxicity and long-term effects. J Neurol Sci. 2006;249(1):76-85.
4. Miyaki K, Nishiwaki Y, Maekawa K, et al. Effects of sarin on the nervous system of subway workers seven years after the Tokyo subway sarin attack. J Occup Health. 2005;47(4):299-304.
5. Smythies J, Golomb B. Nerve gas antidotes. J R Soc Med. 2004;97(1):32.
6. Shewale SV, Anstadt MP, Horenziak M, et al. Sarin causes autonomic imbalance and cardiomyopathy: an important issue for military and civilian health. J Cardiovasc Pharmacol. 2012;60(1):76-87.
7. Tokuda Y, Kikuchi M, Takahashi O, Stein GH. Prehospital management of sarin nerve gas terrorism in urban settings: 10 years of progress after the Tokyo subway sarin attack. Resuscitation. 2006;68(2):193-202.