Discussion:
Metronidazole can rarely cause central nervous system toxicity. Although Metronidazole-induced encephalopathy (MIE) is mostly reported from the United States and Korea, there have been few case reports worldwide including India, Japan, Australia, Canada, United Kingdom, Belgium, Chile, Germany, Israel, Netherlands, Nigeria, Taiwan, Tunisia, and Turkey. Average time taken to develop complications from treatment initiation is 15 days (range 1-90 days), and the average cumulative dose is 93.4g (range, 0.25-1095g) 5. MIE can be suspected in a patient presents cerebellar and brainstem deficits in close relation to metronidazole treatment 6. T2/FLAIR hyperintense lesions in the dentate nuclei, are the best diagnostic finding. In some cases, lesions of the dentate nuclei were not present initially but revealed on re-imaging 7,8. The majority of the cases present cerebellar dysfunction (dysarthria, ataxia, dysmetria, and nystagmus) followed by altered mental status and seizures5, Chorea, myoclonus 9,10 and pure sensorineural hearing loss are also reported 11. The patient has also taking methadone and there is reports of toxic leukoencephalopathy due to methadone 12.
Toxic leukoencephalopathy should be considered in this patients and suspected drug should be discontinued.
Conflict of interest :
The authors declare there is no conflict of interest.