Metronidazole-induced neurotoxicity

Abstract

Rationale: Nervous system toxicity is a rare complication of metronidazole. Prompt identification of metronidazole toxicity combined with a comprehensive physical rehabilitation program is essential to maximizing the patient’s functional outcome. Patient concerns: A 58-year-old female was treated with metronidazole for embolic versus hematogenous spread of bacteria resulting in multifocal brain abscesses. Two weeks after discharge, the patient returned to the emergency department with slurred speech, muscle aches, generalized weakness, inability to ambulate, and poor oral intake. Diagnosis: Head magnetic resonance imaging revealed symmetric enhanced T2/FLAIR signaling in the dentate nuclei were also present bilaterally, a finding pathognomonic for metronidazole toxicity. Intervention: Metronidazole was discontinued, and the patient was enrolled in a comprehensive rehabilitation program. Outcomes: She began inpatient rehabilitation dependent for all activities of daily living and requiring moderate assistance for transfers. She could only walk 10 feet with a front-wheeled walker with a 2-person assist. The patient rapidly improved with a comprehensive rehabilitation program, and due to these improvements, she was discharged after 5 days of inpatient rehabilitation. At the time of discharge, she was independent with all activities of daily living and could walk 160 feet independently with a front-wheeled walker. Lessons: Prompt recognition and discontinuation of metronidazole remains the only known effective treatment. A comprehensive approach to treatment and rehabilitation is achieved with an early referral to rehabilitation services. This is crucial to minimize morbidity and optimize functional outcomes in this patient population.