Pseudocholinesterase Deficiency Clinical Presentation

Updated: Nov 14, 2017
  • Author: Daniel R Alexander, MD; Chief Editor: Karl S Roth, MD  more...
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A personal or family history of an adverse drug reaction to one of the choline ester compounds, such as succinylcholine, mivacurium, or cocaine, may be the only clue suggesting pseudocholinesterase deficiency. Most clinically significant causes of pseudocholinesterase deficiency are due to one or more inherited abnormal alleles that code for the synthesis of the enzyme. These abnormal alleles may result in a failure to produce normal amounts of the enzyme or in production of abnormal forms of pseudocholinesterase with altered structure and lacking full enzymatic function, as described below.

Patients with only partial deficiencies of inherited pseudocholinesterase enzyme activity often do not manifest clinically significant prolongation of paralysis following administration of succinylcholine unless a concomitant acquired cause of pseudocholinesterase deficiency is present. The acquired causes of pseudocholinesterase deficiency include a variety of physiologic conditions, pathologic states, and medications listed below.

Inherited causes

The gene that codes for the pseudocholinesterase enzyme is located at the E1 locus on the long arm of chromosome 3, and 96% of the population is homozygous for the normal pseudocholinesterase genotype, which is designated as EuEu. The remaining 4% of the population carry one or more of the following atypical gene alleles (See Table 1, below) for the pseudocholinesterase gene in either a heterozygous or homozygous fashion.

Table 1. Atypical Gene Alleles for the Pseudocholinesterase Genotype (Open Table in a new window)


Atypical dibucaine-resistant variant

Point mutation


Fluoride-resistant variant

Point mutation


Silent variant

Frameshift mutation

*These alleles may occur either in the homozygous form or in any heterozygous combination with each other, with the normal Eu allele, or with a number of additional rare variant abnormal alleles


In individuals with an inherited form of pseudocholinesterase deficiency, only a single atypical allele is carried in a heterozygous fashion, resulting in a partial deficiency in enzyme activity, which manifests as a slightly prolonged duration of paralysis, longer than 5 minutes but shorter than 1 hour, following administration of succinylcholine. Less than 0.1% of the general population carries 2 pseudocholinesterase gene allele mutations that will produce clinically significant effects from succinylcholine lasting longer than 1 hour.

One rare variant allele of the pseudocholinesterase gene, designated the C5 variant, actually has higher than normal enzyme activity, resulting in relative resistance to the paralytic effects of succinylcholine.

The dibucaine-resistant genetic variant form of pseudocholinesterase is identified by the percent inhibition of hydrolysis of benzyl choline caused by the addition of dibucaine to the pseudocholinesterase enzymatic assay. The dibucaine number is the percent inhibition of hydrolysis of benzyl choline by dibucaine added to the plasma sample. The normal dibucaine number for the homozygous typical genotype (EuEu) is 80%. Individuals homozygous for the atypical dibucaine resistant genotype (EaEa) have a dibucaine number of 20%, which correlates with a marked prolongation of the paralytic effect of standard doses of succinylcholine to well over 1-hour duration. Heterozygotes (EuEa) have intermediate dibucaine numbers and modest prolongation of muscle paralysis with succinylcholine. The EuEa heterozygous genotype is found in 2.5% of the general population, making it more common than all other abnormal pseudocholinesterase genotypes combined.

The fluoride-resistant pseudocholinesterase enzyme variant is identified by its percent inhibition of benzyl choline hydrolysis when fluoride is added to the assay. The fluoride number (percentage inhibition of enzyme activity in the presence of fluoride) is 60% for the EuEu genotype and is 36% for the EfEf genotype. This homozygous fluoride-resistant genotype exhibits mild to moderate prolongation of succinylcholine-induced paralysis. The heterozygous fluoride-resistant genotype usually is clinically insignificant unless accompanied by a second abnormal allele or by a coexisting acquired cause of pseudocholinesterase deficiency.

The most severe form of inherited pseudocholinesterase deficiency occurs in only 1 in 100,000 individuals who are homozygous for the silent Es genotype, with no detectible pseudocholinesterase enzyme activity. These individuals may exhibit prolonged muscle paralysis for as long as 8 hours following a single dose of succinylcholine. Gene mutations that produce silent alleles are caused by frameshift or stop codon mutations, resulting in no functional pseudocholinesterase enzyme synthesis.

Prolonged paralysis due to pseudocholinesterase deficiency has been reported after succinylcholine administration for emergent cesarean section. Abnormal pseudocholinesterase enzyme variants can be present that are undetectable with standard laboratory tests. [10]

Acquired causes

Neonates, elderly individuals, and pregnant women with certain physiologic conditions may have lower plasma pseudocholinesterase activity. [4, 5]

Pathologic conditions that may lower plasma pseudocholinesterase activity include the following:

  • Chronic infections (tuberculosis)

  • Extensive burn injuries

  • Liver disease

  • Malignancy [11]

  • Malnutrition

  • Organophosphate pesticide poisoning

  • Uremia

One study recommended estimation of the pseudocholinesterase level to classify the severity of organophosphorous poisoning and to estimate prognosis. Pseudocholinesterase levels were reduced in all the cases in this study (N = 70), with the mean level being 3,154.16 ± 2,562.40 IU/L. [12]

Iatrogenic causes

Iatrogenic causes of lower plasma pseudocholinesterase activity include plasmapheresis and medications such as the following:

  • Anticholinesterase inhibitors

  • Bambuterol

  • Chlorpromazine

  • Contraceptives

  • Cyclophosphamide

  • Echothiophate eye drops

  • Esmolol

  • Glucocorticoids

  • Hexafluorenium

  • Metoclopramide

  • Monoamine oxidase inhibitors

  • Pancuronium

  • Phenelzine

  • Tetrahydroaminacrine