Metronidazole-induced encephalopathy in a patient with Crohn's disease

Abstract

Metronidazole is a widely used antibiotic for the treatment of anaerobic bacterial infections. Metronidazole-induced encephalopathy (MIEP) is a rare but potentially reversible disease. The mechanism of MIEP remains unclear, and differences in the neurotoxic effects of oral versus intravenous (IV) metronidazole administration have not yet been determined. We report the case of a Crohn's disease (CD) patient who experienced encephalopathy immediately after a single IV dose of metronidazole following long-term exposure to the oral form of the drug. The 64-year-old man with intractable CD experienced a sudden change in mental status, aphasia, and muscle weakness after IV administration of metronidazole. He had previously taken metronidazole orally for 13 years and received intermittent IV metronidazole treatments for CD exacerbation. Brain magnetic resonance imaging (MRI) showed high-intensity signals in the bilateral medial thalamus and the midbrain and pontine tegmentum on fluid-attenuated inversion recovery images. After discontinuation of metronidazole, the high-intensity brain MRI signals resolved and the patient's mental status dramatically improved; however, the patient exhibited mild cognitive dysfunction 2 months after the onset of encephalopathy.

Keywords: Crohn disease; Drug side effects; Metabolic encephalopathy; Metronidazole.

Fig. 1. Abdominal CT finding. CT shows a large enterocutaneous fistula in the middle portion of the abdomen (arrowheads).

Fig. 2. Brain MRI findings. Fluid-attenuated inversion recovery MRI shows high-intensity lesions in the bilateral medial thalamus (A), midbrain tegmentum (B), pontine tegmentum (C), fourth ventricle and dentate nucleus (D), and subcortical white matter (E) (arrows).

Fig. 3. Follow-up brain MRI findings. MR images obtained 7 days after metronidazole discontinuation. A fluid-attenuated inversion recovery image shows the improvement of lesions in the bilateral medial thalamus (A, B); midbrain tegmentum (C); pontine tegmentum, fourth ventricle, and dentate nucleus (D); and subcortical white matter (E).

Fig. 4. Serial results of the Glasgow coma scale (GCS) and total bilirubin testing after cessation of metronidazole (MTZ) treatment. IV, intravenous; tid, three times a day; qd, every day; TPN, total parenteral nutrition.