Case 271: Metronidazole-induced Encephalopathy

Published Online:https://doi.org/10.1148/radiol.2019171079

Characteristic signal abnormality in the cerebellum and brainstem in a patient who has been on a prolonged course of metronidazole that subsequently resolves at follow-up imaging is diagnostic for metronidazole-induced encephalopathy.

History

An 11-year-old boy taking oral antibiotics for Fusobacterium meningitis diagnosed 3 months earlier presented to the emergency department with a 1-week history of intermittent emesis, dizziness, and vertigo and a 1-day history of wobbly gait and bilateral lower extremity paresthesia without confusion. His metabolic profile was normal. Contrast material–enhanced MRI of the brain was performed.

References

  • 1. Riordan T. Human infection with Fusobacterium necrophorum (Necrobacillosis), with a focus on Lemierre’s syndrome. Clin Microbiol Rev 2007;20(4):622–659.
  • 2. Farmakiotis D, Zeluff B. Images in Clinical Medicine. Metronidazole-Associated Encephalopathy. N Engl J Med 2016;374(15):1465.
  • 3. Kuriyama A, Jackson JL, Doi A, Kamiya T. Metronidazole-induced central nervous system toxicity: a systematic review. Clin Neuropharmacol 2011;34(6):241–247.
  • 4. Bahn Y, Kim E, Park C, Park HC. Metronidazole induced encephalopathy in a patient with brain abscess. J Korean Neurosurg Soc 2010;48(3):301–304.
  • 5. Ahmed A, Loes DJ, Bressler EL. Reversible magnetic resonance imaging findings in metronidazole-induced encephalopathy. Neurology 1995;45(3 Pt 1):588–589.
  • 6. Kim E, Na DG, Kim EY, Kim JH, Son KR, Chang KH. MR imaging of metronidazole-induced encephalopathy: lesion distribution and diffusion-weighted imaging findings. AJNR Am J Neuroradiol 2007;28(9):1652–1658.
  • 7. Woodruff BK, Wijdicks EFM, Marshall WF. Reversible metronidazole-induced lesions of the cerebellar dentate nuclei. N Engl J Med 2002;346(1):68–69.
  • 8. Geyer HL, Schaumburg HH, Herskovitz S. Methyl bromide intoxication causes reversible symmetric brainstem and cerebellar MRI lesions. Neurology 2005;64(7):1279–1281.
  • 9. Jan W, Zimmerman RA, Wang ZJ, Berry GT, Kaplan PB, Kaye EM. MR diffusion imaging and MR spectroscopy of maple syrup urine disease during acute metabolic decompensation. Neuroradiology 2003;45(6):393–399.
  • 10. Shen WC, Chiu HH, Chow KC, Tsai CH. MR imaging findings of enteroviral encephaloymelitis: an outbreak in Taiwan. AJNR Am J Neuroradiol 1999;20(10):1889–1895.
  • 11. Huang YT, Chen LA, Cheng SJ. Metronidazole-induced encephalopathy: case report and review literature. Acta Neurol Taiwan 2012;21(2):74–78.
  • 12. Chakrabarti S, Pan K. Metronidazole-induced encephalopathy: an uncommon scenario. N Z Med J 2014;127(1393):120–122.
  • 13. Heaney CJ, Campeau NG, Lindell EP. MR imaging and diffusion-weighted imaging changes in metronidazole (Flagyl)-induced cerebellar toxicity. AJNR Am J Neuroradiol 2003;24(8):1615–1617.
  • 14. Kim DS, Jung JW, Kim JY, et al. Reversible MRI findings in metronidazole-induced cerebellar dysfunction. J Korean Neurol Assoc 1999;17(6):904–907.

Article History

Received: May 16 2017
Revision requested: July 6 2017
Revision received: Aug 7 2017
Accepted: Sept 12 2017
Published online: Oct 17 2019
Published in print: Nov 2019