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*Only for medical professionals to read for reference.
If you encounter similar symptoms, please pay attention to asking for medication history! Metronidazole is a commonly used clinical drug, which is widely used to treat or prevent systemic or local infections caused by anaerobic bacteria, such as oral infections, abdominal infections, pelvic infections, etc.
Female friends may know that it has the effect of treating gynecological diseases
.
What is more familiar is that when our gums are inflamed, we can buy them cheaply at any time in the pharmacy
.
However, "it is a three-point drug", just such a drug with low price, high curative effect, easy to take, low toxicity, "ready to get" drug, the 35-year-old guy suddenly lost his memory, and it turned out to be oral "metronidazole" for the treatment of toothache.
Related
.
In fact, regarding metronidazole-induced encephalopathy, "Medical Neurology Channel" has reported several cases: the patient's sudden speech is slurred, gait wobbly.
.
.
don't miss the cause! The man suddenly had difficulty swallowing and limb weakness.
.
.
It was actually the fault of this common drug! .
.
.
.
.
.
Next, I invite Director Tang Wei of Xinhua Hospital affiliated to Dalian University to analyze this "metronidazole" case for us
.
Case introduction The patient Wang, male, 35 years old, with a postgraduate degree, was admitted to the hospital mainly because of "dizziness and memory loss in February"
.
Medical history: dizziness, unsteady walking, memory loss, often unable to remember where things were placed, often lost things, and incapable of work
.
No speech disorder, no headache, nausea, and vomiting
.
No fever
.
The condition has worsened, and the condition has gotten worse in the past 1 month.
He speaks less and does not communicate with others
.
CT suggests multiple intracranial films with low density shadows, consider demyelinating disease
.
Before 6 months, the patient had been taking metronidazole (0.
2-0.
4 g/time, 3 times/d) due to gum pain, and took 720 tablets successively
.
Nervous system examination: Consciousness, lack of energy, unclear speech and fluency, poor coordination with examinations of memory, calculation ability, and orientation
.
The muscle strength of the upper limbs was 5-level, the muscle strength of the left lower limb was level 3, and the muscle strength of the right lower limb was level 4.
The muscle tension was normal, and there was no involuntary movement
.
Bilateral finger-nose test, rapid rotation movement, and heel-knee-tibia test were abnormal, bilateral brachii, triceps tendon and radial periosteum reflex (+), bilateral knee tendon reflex, ankle reflex (++)
.
Bilateral Babinski sign (+), bilateral Chadock sign did not elicit
.
There was no resistance in the neck, and the Kernig sign was negative
.
Brain MRI plain scan showed bilateral cerebellar dentate nucleus (picture A, picture B), brain stem, temporal lobe (picture C, picture D), hind limbs of internal capsule, corpus callosum pressure part (picture E, picture F), and radiation crown (Figure G, Figure H) T2WI and fluid attenuation inversion recovery (FLAIR) sequence showed uniform high signal shadow
.
Considering the possibility of toxic encephalopathy caused by long-term use of metronidazole, metronidazole was discontinued and symptomatic and supportive treatment was given for 9 days.
After 9 days, her symptoms improved significantly and she was discharged
.
After 3 months of follow-up, the patient's memory improved significantly
.
Figure A, Figure B: Bilateral cerebellar dentate nucleus T2WI and fluid attenuation inversion recovery (FLAIR) sequence show uniform high signal image C, Figure D: Brainstem, temporal lobe T2WI and fluid attenuation inversion recovery (FLAIR) sequence Uniform high-intensity image E, Figure F: T2WI of the posterior limb of the internal capsule, corpus callosum pressure, and fluid attenuation inversion recovery (FLAIR) sequence show uniform high-intensity image G, Figure H: Paraventricular side, radiation crown T2WI and fluid attenuation The FLAIR sequence shows a uniform high signal shadow
.
Combined with the patient’s medical history, clinical symptoms, cranial MRI findings, and symptoms significantly improved after stopping metronidazole, the patient was diagnosed with Metronidazole-Induced Encephalopathy (MIE)
.
Discussion The instructions for metronidazole indicate that it can cause neurological symptoms, such as headache, dizziness, numbness, ataxia, and polyneuritis.
Large doses can cause convulsions
.
Nevertheless, the toxic encephalopathy caused by metronidazole is little known
.
Encephalopathy caused by metronidazole is caused by long-term use of metronidazole.
About 60% are cerebellar dysfunction, and about 23% are changes in mental state
.
Typical clinical manifestations such as nausea, vomiting, headache, uncoordinated movements, dysarthria, unsteady gait, and paresthesias in the limbs, etc.
MRI often prompts multiple lesions in the brain
.
Most of them can be improved by stopping medication.
Studies have shown that metronidazole encephalopathy is closely related to long-term, high-cumulative treatment of metronidazole
.
Cumulative dose> 20 g, the average time for this patient to cause encephalopathy with a cumulative dose of 130 g metronidazole is 68 days, the average daily dose is 1480 mg, and the average daily dose is 1200 mg for the patient with oral medication to 120 days after the onset of disease.
Metronidazole is the first choice for encephalopathy.
The examination method is head MRI, showing the distribution of characteristic lesions
.
Typical lesions are located in the cerebellar dentate nucleus, midbrain, pontine tegmental, dorsal medulla oblongata, and corpus callosum, usually bilaterally symmetrically affected; other areas include the white matter of the cerebral hemisphere and the lower olive nucleus
.
Symmetric lesions of the cerebellar dentate nucleus are often used to distinguish encephalopathy caused by other causes [1,2]
.
The symmetrical involvement of the cerebellar dentate nucleus, brain stem, temporal lobe, posterior limb of the internal capsule, corpus callosum, and radiation crown in this patient are consistent with previous reports in the literature
.
The pathogenesis of metronidazole encephalopathy is unclear
.
Angio-derived and cytotoxic edema, mitochondrial dysfunction, the binding of metronidazole intermediate metabolites to nerve cell nucleic acid, and modification of cerebellar and vestibular gamma-aminobutyric acid receptors are possible mechanisms
.
The metabolic intermediate product of metronidazole is a vitamin B1 analogue, which can inhibit the pyrophosphorylation of vitamin B1, resulting in a decrease in intestinal absorption of vitamin B1
.
Some scholars believe that metronidazole encephalopathy and Wernicke encephalopathy share a certain pathophysiological pathway [3]
.
The clinical symptoms of metronidazole encephalopathy are reversible and can disappear after timely withdrawal
.
Therefore, some scholars believe that the disease is essentially a reversible axonal edema process rather than a demyelinating process [4]
.
The main differential diagnosis of metronidazole encephalopathy includes other toxic encephalopathy, central nervous system demyelinating diseases, and metabolic encephalopathy
.
Among them, Wernicke encephalopathy is the most difficult to distinguish from metronidazole encephalopathy, because the two have similar clinical manifestations and imaging features [3]
.
Discontinuation of metronidazole as soon as possible and supportive treatment are the only effective measures for metronidazole encephalopathy, and vitamin B1 and vitamin B12 nutritional nerve therapy are given
.
The symptoms of most patients with metronidazole encephalopathy can be improved after stopping the drug, and imaging can also be improved [4]
.
References: [1]Ahmed A,Loes DJ,Bressler E L.
Reversible magnetic resonance imaging findings in metronidazole-induced encephalopathy[J].
Neurology,1995,45(3):588-589.
[2]Kim DW,Park JM,Yoon BW,et al.
Metronidazole-induced encephalopathy[J].
Journal of the neurological sciences,2004,224(1-2):107-111.
[3]Deng Chunying,Hu Kun,Mao Wenjing,et al.
Metronidazole A case of azole encephalopathy[J].
Chinese Journal of Neurology,2017,50(6):466-469.
DOI:10.
3760/cma.
j.
issn.
1006-7876.
2017.
06.
016.
[4]Kuriyama A,Jackson JL,Doi A ,et al.
Metronidazole-induced central nervous system toxicity:a systematic review[J].
Clinical neuropharmacology,2011,34(6):241-247.
Audit expert Professor Tang Wei, Doctor of Medicine, Professor, Chief Physician, Graduate Tutor; Dalian Director of the Fourth Department of Neurology, Xinhua Hospital Affiliated to the University
.
Academic part-time job: standing member of the encephalopathy professional committee of the Liaoning Traditional Chinese Medicine Society, standing member of the neurology branch of the Liaoning Traditional Chinese and Western Medicine Society, member of the Psychological Branch of the Liaoning Rehabilitation Medicine Association, member of the Psychiatric Branch of the Liaoning Medical Association, and Clinical Epidemiology of the Liaoning Medical Association Member of the Society of Diseases, Vice Chairman of the Psychiatric Branch of Dalian Medical Association
.
Engaged in neurology clinical scientific research and teaching for more than 20 years, with a solid theoretical foundation of neurology and rich clinical experience, an online celebrity lecturer in the medical field, 300,000 clicks on a single class, 1 second prize of provincial science and technology progress, city science and technology progress 1 second prize, 5 third prizes
.
Presided over 6 provincial and municipal projects, published 60 papers, and edited 2 books
.
If you encounter similar symptoms, please pay attention to asking for medication history! Metronidazole is a commonly used clinical drug, which is widely used to treat or prevent systemic or local infections caused by anaerobic bacteria, such as oral infections, abdominal infections, pelvic infections, etc.
Female friends may know that it has the effect of treating gynecological diseases
.
What is more familiar is that when our gums are inflamed, we can buy them cheaply at any time in the pharmacy
.
However, "it is a three-point drug", just such a drug with low price, high curative effect, easy to take, low toxicity, "ready to get" drug, the 35-year-old guy suddenly lost his memory, and it turned out to be oral "metronidazole" for the treatment of toothache.
Related
.
In fact, regarding metronidazole-induced encephalopathy, "Medical Neurology Channel" has reported several cases: the patient's sudden speech is slurred, gait wobbly.
.
.
don't miss the cause! The man suddenly had difficulty swallowing and limb weakness.
.
.
It was actually the fault of this common drug! .
.
.
.
.
.
Next, I invite Director Tang Wei of Xinhua Hospital affiliated to Dalian University to analyze this "metronidazole" case for us
.
Case introduction The patient Wang, male, 35 years old, with a postgraduate degree, was admitted to the hospital mainly because of "dizziness and memory loss in February"
.
Medical history: dizziness, unsteady walking, memory loss, often unable to remember where things were placed, often lost things, and incapable of work
.
No speech disorder, no headache, nausea, and vomiting
.
No fever
.
The condition has worsened, and the condition has gotten worse in the past 1 month.
He speaks less and does not communicate with others
.
CT suggests multiple intracranial films with low density shadows, consider demyelinating disease
.
Before 6 months, the patient had been taking metronidazole (0.
2-0.
4 g/time, 3 times/d) due to gum pain, and took 720 tablets successively
.
Nervous system examination: Consciousness, lack of energy, unclear speech and fluency, poor coordination with examinations of memory, calculation ability, and orientation
.
The muscle strength of the upper limbs was 5-level, the muscle strength of the left lower limb was level 3, and the muscle strength of the right lower limb was level 4.
The muscle tension was normal, and there was no involuntary movement
.
Bilateral finger-nose test, rapid rotation movement, and heel-knee-tibia test were abnormal, bilateral brachii, triceps tendon and radial periosteum reflex (+), bilateral knee tendon reflex, ankle reflex (++)
.
Bilateral Babinski sign (+), bilateral Chadock sign did not elicit
.
There was no resistance in the neck, and the Kernig sign was negative
.
Brain MRI plain scan showed bilateral cerebellar dentate nucleus (picture A, picture B), brain stem, temporal lobe (picture C, picture D), hind limbs of internal capsule, corpus callosum pressure part (picture E, picture F), and radiation crown (Figure G, Figure H) T2WI and fluid attenuation inversion recovery (FLAIR) sequence showed uniform high signal shadow
.
Considering the possibility of toxic encephalopathy caused by long-term use of metronidazole, metronidazole was discontinued and symptomatic and supportive treatment was given for 9 days.
After 9 days, her symptoms improved significantly and she was discharged
.
After 3 months of follow-up, the patient's memory improved significantly
.
Figure A, Figure B: Bilateral cerebellar dentate nucleus T2WI and fluid attenuation inversion recovery (FLAIR) sequence show uniform high signal image C, Figure D: Brainstem, temporal lobe T2WI and fluid attenuation inversion recovery (FLAIR) sequence Uniform high-intensity image E, Figure F: T2WI of the posterior limb of the internal capsule, corpus callosum pressure, and fluid attenuation inversion recovery (FLAIR) sequence show uniform high-intensity image G, Figure H: Paraventricular side, radiation crown T2WI and fluid attenuation The FLAIR sequence shows a uniform high signal shadow
.
Combined with the patient’s medical history, clinical symptoms, cranial MRI findings, and symptoms significantly improved after stopping metronidazole, the patient was diagnosed with Metronidazole-Induced Encephalopathy (MIE)
.
Discussion The instructions for metronidazole indicate that it can cause neurological symptoms, such as headache, dizziness, numbness, ataxia, and polyneuritis.
Large doses can cause convulsions
.
Nevertheless, the toxic encephalopathy caused by metronidazole is little known
.
Encephalopathy caused by metronidazole is caused by long-term use of metronidazole.
About 60% are cerebellar dysfunction, and about 23% are changes in mental state
.
Typical clinical manifestations such as nausea, vomiting, headache, uncoordinated movements, dysarthria, unsteady gait, and paresthesias in the limbs, etc.
MRI often prompts multiple lesions in the brain
.
Most of them can be improved by stopping medication.
Studies have shown that metronidazole encephalopathy is closely related to long-term, high-cumulative treatment of metronidazole
.
Cumulative dose> 20 g, the average time for this patient to cause encephalopathy with a cumulative dose of 130 g metronidazole is 68 days, the average daily dose is 1480 mg, and the average daily dose is 1200 mg for the patient with oral medication to 120 days after the onset of disease.
Metronidazole is the first choice for encephalopathy.
The examination method is head MRI, showing the distribution of characteristic lesions
.
Typical lesions are located in the cerebellar dentate nucleus, midbrain, pontine tegmental, dorsal medulla oblongata, and corpus callosum, usually bilaterally symmetrically affected; other areas include the white matter of the cerebral hemisphere and the lower olive nucleus
.
Symmetric lesions of the cerebellar dentate nucleus are often used to distinguish encephalopathy caused by other causes [1,2]
.
The symmetrical involvement of the cerebellar dentate nucleus, brain stem, temporal lobe, posterior limb of the internal capsule, corpus callosum, and radiation crown in this patient are consistent with previous reports in the literature
.
The pathogenesis of metronidazole encephalopathy is unclear
.
Angio-derived and cytotoxic edema, mitochondrial dysfunction, the binding of metronidazole intermediate metabolites to nerve cell nucleic acid, and modification of cerebellar and vestibular gamma-aminobutyric acid receptors are possible mechanisms
.
The metabolic intermediate product of metronidazole is a vitamin B1 analogue, which can inhibit the pyrophosphorylation of vitamin B1, resulting in a decrease in intestinal absorption of vitamin B1
.
Some scholars believe that metronidazole encephalopathy and Wernicke encephalopathy share a certain pathophysiological pathway [3]
.
The clinical symptoms of metronidazole encephalopathy are reversible and can disappear after timely withdrawal
.
Therefore, some scholars believe that the disease is essentially a reversible axonal edema process rather than a demyelinating process [4]
.
The main differential diagnosis of metronidazole encephalopathy includes other toxic encephalopathy, central nervous system demyelinating diseases, and metabolic encephalopathy
.
Among them, Wernicke encephalopathy is the most difficult to distinguish from metronidazole encephalopathy, because the two have similar clinical manifestations and imaging features [3]
.
Discontinuation of metronidazole as soon as possible and supportive treatment are the only effective measures for metronidazole encephalopathy, and vitamin B1 and vitamin B12 nutritional nerve therapy are given
.
The symptoms of most patients with metronidazole encephalopathy can be improved after stopping the drug, and imaging can also be improved [4]
.
References: [1]Ahmed A,Loes DJ,Bressler E L.
Reversible magnetic resonance imaging findings in metronidazole-induced encephalopathy[J].
Neurology,1995,45(3):588-589.
[2]Kim DW,Park JM,Yoon BW,et al.
Metronidazole-induced encephalopathy[J].
Journal of the neurological sciences,2004,224(1-2):107-111.
[3]Deng Chunying,Hu Kun,Mao Wenjing,et al.
Metronidazole A case of azole encephalopathy[J].
Chinese Journal of Neurology,2017,50(6):466-469.
DOI:10.
3760/cma.
j.
issn.
1006-7876.
2017.
06.
016.
[4]Kuriyama A,Jackson JL,Doi A ,et al.
Metronidazole-induced central nervous system toxicity:a systematic review[J].
Clinical neuropharmacology,2011,34(6):241-247.
Audit expert Professor Tang Wei, Doctor of Medicine, Professor, Chief Physician, Graduate Tutor; Dalian Director of the Fourth Department of Neurology, Xinhua Hospital Affiliated to the University
.
Academic part-time job: standing member of the encephalopathy professional committee of the Liaoning Traditional Chinese Medicine Society, standing member of the neurology branch of the Liaoning Traditional Chinese and Western Medicine Society, member of the Psychological Branch of the Liaoning Rehabilitation Medicine Association, member of the Psychiatric Branch of the Liaoning Medical Association, and Clinical Epidemiology of the Liaoning Medical Association Member of the Society of Diseases, Vice Chairman of the Psychiatric Branch of Dalian Medical Association
.
Engaged in neurology clinical scientific research and teaching for more than 20 years, with a solid theoretical foundation of neurology and rich clinical experience, an online celebrity lecturer in the medical field, 300,000 clicks on a single class, 1 second prize of provincial science and technology progress, city science and technology progress 1 second prize, 5 third prizes
.
Presided over 6 provincial and municipal projects, published 60 papers, and edited 2 books
.
