Metronidazole neurotoxicity in late liver transplantation

Neurotoxidade por metronidazol em pós-operatório de transplante de fígado

A 67-year-old female developed subacute peripheral neuropathy, nystagmus and encephalopathy. She was on continuous metronidazole use for 65 days for a liver abscess after receiving a transplantation. Diagnostic workup revealed a sensory axonal polyneuropathy in electroneuromyography. Brain magnetic resonance imaging (MRI) showed hyperintensities at the dentate nucleus and pons (Figure 1). Metronidazole treatment was discontinued and within the first week the patient evolved with complete improvement of encephalopathy. However, she maintained the neuropathy symptoms. A control brain MRI was normal after 30 days (Figure 2). Metronidazole neurotoxicity was previously reported with these same imaging findings and clinical course^1,2,3,4.

Figure 1.
Brain MRI with symmetric hyperintensity on axial T2-weighted images at the dentate nucleus (A, B) and pons (B), and increased signal on axial FLAIR images (C, D).

Figure 2.
Axial FLAIR image 30 days after metronidazole interruption demonstrates complete reversal of signal changes

References

• ¹
  Goolsby TA, Jakeman B, Gaynes RP. Clinical relevance of metronidazole and peripheral neuropathy: a systematic review of the literature. Int J Antimicrob Agents. 2018 Mar;51(3):319-25. https://doi.org/10.1016/j.ijantimicag.2017.08.033
  » https://doi.org/10.1016/j.ijantimicag.2017.08.033
• ²
  Agarwal A, Kanekar S, Sabat S, Thamburaj K. Metronidazole-induced cerebellar toxicity. Neurol Int. 2016 Apr;8(1):6365. https://doi.org/10.4081/ni.2016.6365
  » https://doi.org/10.4081/ni.2016.6365
• ³
  Iemura T, Kitano T, Ishii A, Hishizawa M, Kondo T, Yamashita K. Metronidazole-induced encephalopathy during treatment for refractory diarrhea after cord blood transplantation. Clin J Gastroenterol. 2019 Oct;12(5):414-9. https://doi.org/10.1007/s12328-019-00959-x
  » https://doi.org/10.1007/s12328-019-00959-x
• ⁴
  Woodruff BK, Wijdicks EFM, Marshall WF. Reversible metronidazole-induced lesions od the cerebellar dentate nuclei. N Engl J Med. 2002 Jan;346(1):68-9. https://doi.org/10.1056/NEJM200201033460117
  » https://doi.org/10.1056/NEJM200201033460117

Publication Dates

• Publication in this collection
  9 Apr 2020
• Date of issue
  May 2020

History

• Reviewed
  15 Sept 2019
• Received
  21 Oct 2019
• Accepted
  10 Nov 2019