Q: 32 year old male who is on long term high dose metronidazole for multidrug-resistant tuberculosis developed seizures and has been admitted to ICU. Which of the following diagnostic workup may confirm Metronidazole induced seizure?
A) Magnetic Resonance Imaging (MRI)
B) Lumbar Puncture (LP)
Answer: A
Metronidazole may cause nervous system toxicity with manifestations of seizures, peripheral neuropathy, dizziness, vertigo, ataxia, confusion, encephalopathy, irritability, weakness, insomnia, headache, and tremors. This is a dose dependent side effect. MRI in those patients may show bilateral symmetric T2 hyperintense lesions. Fortunately, these side effects and MRI findings are reversible.
LP may show metronidazole level but it just suggest expected penetration in nervous system but not the reason for toxicity. Metronidazole penetrates the blood-brain barrier and cerebrospinal fluid (CSF) levels approximate 45 percent of corresponding serum concentrations. Metronidazole has excellent penetration into brain abscesses.
#neurology
#pharmacology
References:
1. Kusumi RK, Plouffe JF, Wyatt RH, Fass RJ. Central nervous system toxicity associated with metronidazole therapy. Ann Intern Med 1980; 93:59.
2. Farmakiotis D, Zeluff B. IMAGES IN CLINICAL MEDICINE. Metronidazole-Associated Encephalopathy. N Engl J Med 2016; 374:1465.
3. Kim E, Na DG, Kim EY, et al. MR imaging of metronidazole-induced encephalopathy: lesion distribution and diffusion-weighted imaging findings. AJNR Am J Neuroradiol 2007; 28:1652.
4. Lefkowitz A, Shadowitz S. Reversible cerebellar neurotoxicity induced by metronidazole. CMAJ 2018; 190:E961.
5. Jokipii AM, Myllylä VV, Hokkanen E, Jokipii L. Penetration of the blood brain barrier by metronidazole and tinidazole. J Antimicrob Chemother 1977; 3:239.
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