Clinical, neuroimaging and pathological features of 5-nitroimidazole-induced encephalo-neuropathy in two patients: Insights into possible pathogenesis

Abstract

We report two patients manifesting with involvement of central and peripheral nervous system with brain magnetic resonance imaging (MRI) changes and pathological features of neuropathy possibly due to harmful and chronic use of various nitroimidazole group of medications for recurrent diarrheal illness. Patient 1, a 21-year-old man with obsessive-compulsive disorder, impulsive behavior and harmful use of substance (tinidazole), had developed encephalopathy and biopsy-proven neuropathy with partial remission. The MRI of brain showed involvement of bilateral caudate, lentiform and dentate nuclei, and splenium, with contrast enhancement of the caudate and putaminal lesions and restricted diffusion of the splenial lesion. Patient 2 was a 50-year-old woman with irritable bowel syndrome and was on harmful use of tinidazole and metronidazole. She manifested with encephalopathy, ataxia, and neuropathy. Her MRI of brain revealed involvement of bilateral putamen, dentate nuclei and periventricular white matter with restricted diffusion. Sural nerve biopsy revealed evidence of vasculitic neuropathy. At follow-up, there was definite, though incomplete, recovery in both the patients. The MRI alterations improved completely in patient 2 and substantially in patient 1. Increasing awareness among the physicians may enable early recognition of potentially reversible neurotoxicity and avoid unwarranted prescription of such medications.

Metronidazole-induced cerebellar toxicity

“…Lower ADC values may suggest more acute nature of cell damage. 1 , 8 Lesions are generally reversible with complete resolution of signal changes on follow-up imaging. Both of our patients had symmetric involvement of the dentate nuclei with FLAIR signal changes.…”

Metronidazole-Induced Toxic Neuropathy With the “Boomerang” Sign

“…These patients often have associated disorders of gut-brain interaction, like diarrhea-predominant irritable bowel syndrome (IBS-D). Hence, sometimes the person does not stop the drug or adhere to the physician's prescription 7 . We herein report the case of a middle-aged Indian man with an anxious and obsessive premorbid trait, who presented with unremitting symptoms of peripheral neuropathy along with a silent callosal lesion in the splenium (“boomerang” sign).…”

Encephalitis with reversible splenial and deep cerebral white matter lesions associated with Epstein–Barr virus infection in adults

“…Compared with the literature, the present case reports suggest that MERS could be more severe in adults than in children. Among the rare adult case reports, we found two cases of EBV encephalitis, 9 , 10 one of tick-borne encephalitis (CSF WBC 33/μL), 13 one of anti-Yo rhombencephalitis, 14 one of viral encephalitis of unknown etiology (CSF WBC 408/μL), 15 one of influenza virus A encephalitis, one of HIV encephalitis, and some cases of MERS associated with systemic infections. 11 , 16 , 17 Among these cases, CSF WBC count and protein level were both unremarkable.…”

“…MERS occurs more commonly in children in Japan and East Asia. 1 – 6 Epstein–Barr virus (EBV) has been associated on rare occasions with a variety of central nervous system complications, 1 , 7 usually in pediatric patients 8 – 10 and almost exclusively during acute primary infections. 7 Here, we report three cases of adult MERS induced by EBV infection.…”