Posterior Reversible Encephalopathy Syndrome (PRES) is a clinico-radiological diagnosis characterized by acute or subacute neurological symptoms. A 27-year-old woman at 35 weeks of pregnancy, who presented with generalized tonic-clonic seizures had persistently low Glasgow Coma Scale (GCS) score after delivery of the baby. Magnetic Resonance Imaging (MRI) of the brain showed T-2 Fluid Attenuated Inversion Recovery (FLAIR) hyperintensities in the brainstem, bilateral medial cerebellar hemispheres, bilateral medial temporal lobes, bilateral thalami, lentiform and caudate nuclei, and bilateral fronto-parieto-occipital lobes. There was diffusion restriction in bilateral caudate nuclei, left thalamus and right frontal lobe, and microhemorrhages in the left thalamus. These findings were suggestive of central variant PRES. She improved with strict blood pressure control and anti-edema measures. A repeat MRI brain on day 10 showed significant improvement, and she had no residual neurological deficits. The central variant of PRES is a rare entity that has to be considered in a patient presenting with neurological deficits in the setting of uncontrolled blood pressure, eclampsia, immunomodulatory medication use, or renal failure. While most patients with PRES fully recover with timely therapy targeted at reversing the primary cause, some may have residual neurological deficits or rarely, die.
A 73-year-old man who presented with fever and abdominal discomfort was diagnosed to have a liver abscess. He was treated with antimicrobials which included metronidazole. One month into treatment, he developed neurological symptoms and signs that were suggestive of cerebellar pathology. MRI of the brain showed T2/fluid attenuated inversion recovery hyperintensities involving bilateral dentate, fastigial and interpositus nuclei. After excluding common aetiologies, the possibility of metronidazole-induced neurotoxicity was considered. After stopping metronidazole, his symptoms and signs resolved. A subsequent MRI scan of the brain showed reversal of changes. Neurotoxicity caused by metronidazole is an uncommon adverse effect of a commonly used antimicrobial drug and should be considered in the appropriate clinical scenario.
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