Serially Changing Metronidazole-Induced Encephalopathy

Metronidazole is a 5-nitroimidazole compound that is a fairly well-tolerated antiprotozoal and antibacterial agent.Occasionally, it can manifest adverse neurologic effects.Variable brain magnetic resonance (MR) imaging abnormalities that are a feature of metronidazole-induced encephalopathy (MIE) have been identified in the cerebellar dentate nucleus, inferior colliculus, midbrain, basal ganglia, corpus callosum, or subcortical white matter.1,2 Although many cases of MIE have been reported with a focus on the reversibility or lesion distribution, we describe additional characteristic imaging findings of MIE that showed a serially changing pattern of reversible and unilateral lesions following discontinuation of metronidazole therapy, despite metabolic encephalopathy.A 46-year-old man had been an alcoholic for 20 years but had stopped drinking four months earlier.Recently, he had been diagnosed by chest X-ray with pneumonia with pleural effusion, and he had been treated with intravenous ceftriaxone (1000 mg/day) and metronidazole (1500 mg/day) for nine days and then with 400 mg of oral moxifloxacin and 1500 mg of metronidazole per day for 15 days.Twenty-four days after taking the metronidazole medication, the patient was hospitalized with complaints of tingling sensations in both arms one day before admission and dysarthria on the day of admission.By now, the patient had consumed about 36 g of the drug.He had no history of starvation, other drug medications, or trauma.Upon neurological examination, he was alert but confused.A cranial nerve examination was normal except for dysarthria.He presented with trivial paresthesia in both arms but did not exhibit objective sensory impairment.His motor power, deep tendon reflexes, cerebellar functioning, and gait were normal.Brain MR imaging (Intera 1.5T 10.3 version, Eindhoven, Netherlands) revealed high-signal lesions in the genu and splenium of the corpus callosum on initial diffusion-weighted images [DWI; repetition time/echo time (TR/TE), 6500/110 ms; b-values = 1000 s/mm 2 ] with correspondingly low apparent diffusion coefficient (ADC) maps (Figure 1).Upon physical examination, the patient's vital signs were stable, and there was no finding of malnutrition.Serum laboratory findings, including electrolytes, liver and kidney panels, and vitamin B 1 , B 12 , and folate levels, were all within normal limits.Serum anti-human immunodeficiency virus (HIV) antibody, urine, cerebrospinal fluid (CSF) studies, and culture studies, including blood, urine, and cerebrospinal fluid, all were negative.We suspected that he was suffering from MIE, and metronidazole therapy was discontinued.On the third day following metronidazole discontinuation, his mental status

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