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Kano Y. A man with neurologic symptoms during liver abscess treatment. Eur J Intern Med 2024; 124:132-133. [PMID: 38413329 DOI: 10.1016/j.ejim.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 02/24/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Yasuhiro Kano
- Department of Emergency and General Medicine, Tokyo Metropolitan Tama Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo 183-8524, Japan.
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2
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Martínez-Rosas V, Navarrete-Vázquez G, Ortega-Cuellar D, Arreguin-Espinosa R, Pérez de la Cruz V, Calderón-Jaimes E, Enríquez-Flores S, Wong-Baeza C, Baeza-Ramírez I, Morales-Luna L, Vázquez-Bautista M, Rojas-Alarcón MA, Hernández-Ochoa B, Gómez-Manzo S. Imidazole Carbamates as a Promising Alternative for Treating Trichomoniasis: In Vitro Effects on the Growth and Gene Expression of Trichomonas vaginalis. Molecules 2024; 29:2585. [PMID: 38893461 PMCID: PMC11173628 DOI: 10.3390/molecules29112585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/21/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
Metronidazole (MTZ) is the most common drug used against Trichomonas vaginalis (T. vaginalis) infections; however, treatment failures and high rates of recurrence of trichomoniasis have been reported, suggesting the presence of resistance in T. vaginalis to MTZ. Therefore, research into new therapeutic options against T. vaginalis infections has become increasingly urgent. This study investigated the trichomonacidal activity of a series of five imidazole carbamate compounds (AGR-1, AGR-2, AGR-3, AGR-4, and AGR-5) through in vitro susceptibility assays to determine the IC50 value of each compound. All five compounds demonstrated potent trichomonacidal activity, with IC50 values in the nanomolar range and AGR-2 being the most potent (IC50 400 nM). To gain insight into molecular events related to AGR-induced cell death in T. vaginalis, we analyzed the expression profiles of some metabolic genes in the trophozoites exposed to AGR compounds and MTZ. It was found that both AGR and MTZ compounds reduced the expression of the glycolytic genes (CK, PFK, TPI, and ENOL) and genes involved in metabolism (G6PD, TKT, TALDO, NADHOX, ACT, and TUB), suggesting that disturbing these key metabolic genes alters the survival of the T. vaginalis parasite and that they probably share a similar mechanism of action. Additionally, the compounds showed low cytotoxicity in the Caco-2 and HT29 cell lines, and the results of the ADMET analysis indicated that these compounds have pharmacokinetic properties similar to those of MTZ. The findings offer significant insights that can serve as a basis for future in vivo studies of the compounds as a potential new treatment against T. vaginalis.
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Affiliation(s)
- Víctor Martínez-Rosas
- Laboratorio de Bioquímica Genética, Instituto Nacional de Pediatría, Secretaría de Salud, Mexico City 04530, Mexico; (V.M.-R.); (L.M.-L.); (M.V.-B.); (M.A.R.-A.)
- Programa de Posgrado en Biomedicina y Biotecnología Molecular, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City 11340, Mexico
| | - Gabriel Navarrete-Vázquez
- Facultad de Farmacia, Universidad Autónoma del Estado de Morelos, Av. Universidad 1001, Chamilpa, Cuernavaca 62209, Mexico;
| | - Daniel Ortega-Cuellar
- Laboratorio de Nutrición Experimental, Instituto Nacional de Pediatría, Secretaría de Salud, Mexico City 04530, Mexico;
| | - Roberto Arreguin-Espinosa
- Departamento de Química de Biomacromoléculas, Instituto de Química, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico;
| | - Verónica Pérez de la Cruz
- Neurobiochemistry and Behavior Laboratory, National Institute of Neurology and Neurosurgery “Manuel Velasco Suárez”, Mexico City 14269, Mexico;
| | - Ernesto Calderón-Jaimes
- Laboratorio de Inmunoquímica, Hospital Infantil de México Federico Gómez, Secretaría de Salud, Mexico City 06720, Mexico;
| | - Sergio Enríquez-Flores
- Laboratorio de Biomoléculas y Salud Infantil, Instituto Nacional de Pediatría, Secretaría de Salud, Mexico City 04530, Mexico;
| | - Carlos Wong-Baeza
- Laboratorio de Biomembranas, Departamento de Bioquímica, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City 11350, Mexico; (C.W.-B.); (I.B.-R.)
| | - Isabel Baeza-Ramírez
- Laboratorio de Biomembranas, Departamento de Bioquímica, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City 11350, Mexico; (C.W.-B.); (I.B.-R.)
| | - Laura Morales-Luna
- Laboratorio de Bioquímica Genética, Instituto Nacional de Pediatría, Secretaría de Salud, Mexico City 04530, Mexico; (V.M.-R.); (L.M.-L.); (M.V.-B.); (M.A.R.-A.)
- Posgrado en Ciencias Biológicas, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
| | - Montserrat Vázquez-Bautista
- Laboratorio de Bioquímica Genética, Instituto Nacional de Pediatría, Secretaría de Salud, Mexico City 04530, Mexico; (V.M.-R.); (L.M.-L.); (M.V.-B.); (M.A.R.-A.)
- Programa de Posgrado en Biomedicina y Biotecnología Molecular, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City 11340, Mexico
| | - Miriam Abigail Rojas-Alarcón
- Laboratorio de Bioquímica Genética, Instituto Nacional de Pediatría, Secretaría de Salud, Mexico City 04530, Mexico; (V.M.-R.); (L.M.-L.); (M.V.-B.); (M.A.R.-A.)
- Programa de Posgrado en Biomedicina y Biotecnología Molecular, Escuela Nacional de Ciencias Biológicas, Instituto Politécnico Nacional, Mexico City 11340, Mexico
| | - Beatriz Hernández-Ochoa
- Laboratorio de Inmunoquímica, Hospital Infantil de México Federico Gómez, Secretaría de Salud, Mexico City 06720, Mexico;
| | - Saúl Gómez-Manzo
- Laboratorio de Bioquímica Genética, Instituto Nacional de Pediatría, Secretaría de Salud, Mexico City 04530, Mexico; (V.M.-R.); (L.M.-L.); (M.V.-B.); (M.A.R.-A.)
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Klevor R, Jarti M, Chraa M, Louhab N, Krati K, Kissani N. Metronidazole-Induced Encephalopathy With Probable Crohn Encephalitis: A Case Report. Clin Neuropharmacol 2024; 47:104-107. [PMID: 38743605 DOI: 10.1097/wnf.0000000000000592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
OBJECTIVES Metronidazole central nervous system toxicity is a rare finding in patients receiving the medication. We report a peculiar case of metronidazole central nervous system toxicity in which both the underlying condition (Crohn disease) and the drugs used to treat it are potential causes of encephalopathy. METHODS A 26-year-old female with 6-year history of Crohn's disease for 6 years presented acute-onset encephalopathy. We provide bibliographic evidence to support metronidazole toxicity and potential Crohn disease-associated neurologic involvement. RESULTS The patient presented dystonia, cerebellar ataxia, and altered mental status. Magnetic resonance imaging of the brain revealed typical findings of metronidazole toxicity and white matter involvement of the centrum semiovale. Immunoelectrophoresis and immunofixation of serum and cerebrospinal fluid proteins were consistent with a systemic inflammatory process. We concluded on an association between drug toxicity and probable Crohn-associated neurologic involvement. Metronidazole was stopped and the patient was placed on vitamin therapy and diazepam to control dystonia. She deteriorated and was transferred to the intensive care unit where she expired. CONCLUSIONS Acute behavioral changes in a young patient constitute an emergency and differential diagnoses should include infective, inflammatory, metabolic, and toxic causes. Metronidazole is a potential toxic etiology.
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Affiliation(s)
| | - Mariama Jarti
- Gastro-entero-hepatology, Mohammed VI University Medical Center, Marrakesh, Morocco
| | | | | | - Khadija Krati
- Gastro-entero-hepatology, Mohammed VI University Medical Center, Marrakesh, Morocco
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Lee SJ, Kim J, Lee KH, Lee JA, Kim CH, Ahn JY, Jeong SJ, Ku NS, Choi JY, Yeom JS, Kim SR, Kim JH. Frequency and Risk Factor Analysis for Metronidazole-Associated Neurologic Adverse Events. J Gen Intern Med 2024; 39:912-920. [PMID: 38093026 DOI: 10.1007/s11606-023-08566-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 12/01/2023] [Indexed: 05/08/2024]
Abstract
BACKGROUND Little is known about the risk factors and frequency of metronidazole-associated neurological adverse events. OBJECTIVE To investigate the risk factors and frequency of metronidazole-associated neurological adverse events. DESIGN This retrospective study contained two parts. First, we investigated metronidazole treatment-associated neurologic adverse events by performing a population-based cohort study using the Korea Adverse Event Reporting System (KAERS) database from January 2011 to December 2020. Second, we conducted a matched case-control study based on a retrospective cohort of patients treated with metronidazole between January 2006 and July 2021 at a tertiary hospital in South Korea. The data analysis was performed from August 2021 to April 2022. PARTICIPANTS In the case-control study, case patients were defined as those diagnosed with metronidazole-associated encephalopathy or peripheral neuropathy during the study period with causal assessment based on the clinical diagnoses and findings from associated tests. In a ratio of 1:3, case patients were compared to a control group of patients prescribed metronidazole without neurologic adverse events matched for age and cumulative dose of metronidazole. MAIN MEASURES Frequency and risk factors for metronidazole-associated neurological adverse events. KEY RESULTS Overall, 2,309 cases of neurologic adverse events were reported to the KAERS from 2011 to 2020, and the number of reported neurological adverse events showed an increasing trend. Further, 92,838 patients were prescribed metronidazole during the study period at the Severance Hospital; 54 patients were diagnosed with metronidazole-associated encephalopathy or peripheral neuropathy, 40 with central and 28 with peripheral nervous system adverse events. Liver cirrhosis, chronic kidney disease, intravenous administration, and lower body weight were identified as risk factors for these adverse events. CONCLUSIONS The number of reported metronidazole-associated neurological adverse events are increasing. Prolonged metronidazole treatment in patients with the aforementioned factors requires careful examination for neurological adverse events.
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Affiliation(s)
- Se Ju Lee
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
- Division of Infectious Diseases, Department of Internal Medicine, Inha University College of Medicine, Incheon, Republic of Korea
| | - Jinnam Kim
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ki Hyun Lee
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Ah Lee
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Chang Hyup Kim
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Young Ahn
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Su Jin Jeong
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Nam Su Ku
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Yong Choi
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon-Sup Yeom
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung-Ryeol Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Kyounggi-Do, Republic of Korea.
| | - Jung Ho Kim
- Division of Infectious Diseases, Department of Internal Medicine and AIDS Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Barba L, Carrubba C, Spindler K, Weise CM, Sachs T, Foschi M, D'Anna L, Sehm B, Ibe R, Elolf E, Strauss C, Otto M, Mensch A, Abu-Rumeileh S. Posterior reversible encephalopathy syndrome associated with antibiotic therapy: a case report and systematic review. Neurol Sci 2024:10.1007/s10072-024-07545-1. [PMID: 38679625 DOI: 10.1007/s10072-024-07545-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/20/2024] [Indexed: 05/01/2024]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is an acute neurological condition associated with different etiologies, including antibiotic therapy. To date, most data regarding antibiotic-related PRES are limited to case reports and small case series. Here, we report a novel case description and provide a systematic review of the clinico-radiological characteristics and prognosis of available cases of PRES associated with antibiotic therapy. We performed a systematic literature search in PubMed and Scopus from inception to 10 January 2024, following PRISMA guidelines and a predefined protocol. The database search yielded 12 subjects (including our case). We described the case of a 55-year-old female patient with PRES occurring one day after administration of metronidazole and showing elevated serum neurofilament light chain protein levels and favorable outcome. In our systematic review, antibiotic-associated PRES was more frequent in female patients (83.3%). Metronidazole and fluoroquinolones were the most reported antibiotics (33.3% each). Clinical and radiological features were comparable to those of PRES due to other causes. Regarding the prognosis, about one third of the cases were admitted to the intensive care unit, but almost all subjects (90.0%) had a complete or almost complete clinical and radiological recovery after prompt cessation of the causative drug. Antibiotic-associated PRES appears to share most of the characteristics of classic PRES. Given the overall good prognosis of the disease, it is important to promptly diagnose antibiotic-associated PRES and discontinue the causative drug.
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Affiliation(s)
- Lorenzo Barba
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Carmelo Carrubba
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Kai Spindler
- Department of Neurosurgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Christopher M Weise
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Torben Sachs
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Lucio D'Anna
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
- Division of Brain Sciences, Department of Medicine, Hammersmith Campus, Imperial College London, London, UK
| | - Bernhard Sehm
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Richard Ibe
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Erck Elolf
- Department of Radiology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Christian Strauss
- Department of Neurosurgery, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Markus Otto
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Alexander Mensch
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Samir Abu-Rumeileh
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany.
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Kim JH, Kim T, Kim W, Kim SH, Hong YJ, Lim E, Bae DW, Noh SM, Lee J. The incidence and predictors of antibiotic-associated encephalopathy: a multicenter hospital-based study. Sci Rep 2024; 14:8747. [PMID: 38627483 PMCID: PMC11021399 DOI: 10.1038/s41598-024-59555-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 04/12/2024] [Indexed: 04/19/2024] Open
Abstract
This study aimed to evaluate the incidence and likelihood of antibiotic-associated encephalopathy (AAE), comparing rates among the classes of antibiotics in monotherapy or in combination therapy. We also investigated the associations between the incidence of AAE and the glomerular filtration rate (GFR) and electroencephalogram features. Consecutive admissions that used any kind of antibiotics to treat infectious diseases were identified from six hospitals. We classified antibiotics according to three distinct pathophysiologic mechanisms and clinical subtypes. We searched for the incidence of AAE as the primary outcome. A total of 97,433 admission cases among 56,038 patients was identified. Cases that received type 1 antibiotics had significantly more frequent AAE compared to those that received type 2 antibiotics (adjusted odds ratio [OR], 2.62; 95% confidence interval [CI] 1.15-5.95; P = 0.021). Combined use of type 1 + 2 antibiotics was associated with a significantly higher incidence of AAE compared to the use of type 2 antibiotics alone (adjusted OR, 3.44; 95% CI 1.49-7.93; P = 0.004). Groups with GFR < 60 mL/min/1.73 m2 had significantly higher incidence rates of AAE compared to those with GFRs ≥ 90 mL/min/1.73 m2 among cases that received type 1 + 2 antibiotics. Detection of spike-and-wave or sharp-and-wave patterns on electroencephalogram was significantly more common in the combination therapy group. Combination use of antibiotics was associated with a higher incidence of AAE compared to monotherapy. The incidence of AAE significantly increased as renal function decreased, and epileptiform discharges were more likely to be detected in cases receiving combined antibiotics.
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Affiliation(s)
- Jean Hee Kim
- Department of Neurology, Eunpyeong St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Taewon Kim
- Department of Neurology, Incheon St. Mary's Hospital, The Catholic University of Korea, #56 Dongsu-Ro, Bupyeong-Gu, Incheon, 21431, South Korea.
| | - Woojun Kim
- Department of Neurology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Seong-Hoon Kim
- Department of Neurology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Yun Jeong Hong
- Department of Neurology, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Eunyae Lim
- Department of Neurology, Yeouido St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Dae Woong Bae
- Department of Neurology, St. Vincent's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Sang-Mi Noh
- Department of Neurology, St. Vincent's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Jieun Lee
- Department of Neurology, Bucheon St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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Andersen MA, Gregersen R, Petersen TS, Wang JN, Petersen J, Jimenez-Solem E. Association Between First-time Neurologic Events and Metronidazole Treatment: A Case-time Control Study. Clin Ther 2024; 46:307-312. [PMID: 38493002 DOI: 10.1016/j.clinthera.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/17/2023] [Accepted: 02/12/2024] [Indexed: 03/18/2024]
Abstract
PURPOSE Metronidazole, a widely used antimicrobial medication, has been linked to neurologic adverse drug reactions. This study investigates the association between metronidazole use and first-time neurologic events. METHODS We conducted a case-time-control study using data from the Danish National Patient Register and the National Prescription Register in years 2013 to 2021. Patients with a first-time diagnosis of encephalopathy, cerebellar dysfunction, or peripheral neuropathy were included. Conditional logistic regression analyses were performed to estimate the risk of neurologic events associated with metronidazole use. FINDINGS Out of 476,066 first-time metronidazole prescriptions, the 100-day cumulative incidence of peripheral neuropathy was 0.016%, and 0.002% for cerebellar dysfunction or encephalopathy. In the case-time control study, we identified 17,667 persons with a first-time neurologic event and were included for the analysis. The estimated odds ratio for the combined neurologic events was 0.98 (95% CI, 0.59-1.64, P = 0.95) with no statistically significant association across different subgroups and time windows. IMPLICATIONS Our findings suggest that metronidazole-induced neurologic events may be rarer than previously described, and we did not find any consistent or statistically significant association between metronidazole exposure. Nonetheless, clinicians should remain vigilant to potential neurologic risks in patients receiving metronidazole, to ensure its safe and effective use.
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Affiliation(s)
- Michael Asger Andersen
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark.
| | - Rasmus Gregersen
- Department of Emergency Medicine, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark; Center for Clinical Research and Prevention, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark; Section of Biostatistics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tonny Studsgaard Petersen
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Joanna Nan Wang
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark; Center for Clinical Research and Prevention, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark; Copenhagen Phase IV Unit (Phase4CPH), Department of Clinical Pharmacology, Center for Clinical Research and Prevention, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Janne Petersen
- Center for Clinical Research and Prevention, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark; Section of Biostatistics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Copenhagen Phase IV Unit (Phase4CPH), Department of Clinical Pharmacology, Center for Clinical Research and Prevention, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Espen Jimenez-Solem
- Department of Clinical Pharmacology, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Copenhagen Phase IV Unit (Phase4CPH), Department of Clinical Pharmacology, Center for Clinical Research and Prevention, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
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8
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Coşkun F, Yalçın E, Çavuşoğlu K. Metronidazole promotes oxidative stress and DNA fragmentation-mediated myocardial injury in albino mice. CHEMOSPHERE 2024; 352:141382. [PMID: 38331262 DOI: 10.1016/j.chemosphere.2024.141382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/03/2024] [Accepted: 02/02/2024] [Indexed: 02/10/2024]
Abstract
The purpose of the present study was to investigate the cardiotoxic effects of Metronidazole (Mtz) in albino mice. The mice were divided into four experimental groups: Gp.I (control group): saline, Gp.II:125 mg/kg b.w Mtz, Gp.III:250 mg/kg b.w, Gp.IV:500 mg/kg b.w Mtz. Heart weight ratio, markers of cardiac injury, markers of oxidative stress, histopathological examinations, DNA fragmentation and spectral analysis were used to determine cardiotoxicity. Administration of 125-500 mg/kg Mtz caused an increase in heart weight and a decrease in body weight. Administration of 500 mg/kg Mtz increased heart weight by 35.5% and decreased body weight by 21.9% compared with control. Mtz-treated mice showed a significant increase in cardiac injury biomarkers and serious alterations in cardiac oxidative stress markers. Histopathological changes of cardiac tissues observed in mice treated with Mtz include myocardial hypertrophy, fibrosis, myocarditis, separation of the muscle fibers, congestion-narrowing in vessels, necrosis, myocardium-vacuolation, myocytolysis, myocyte degeneration, nuclear aggregation, cytoplasmic fragmentation and prevalent nuclei. Mtz treatment already resulted in a significant decrease in the percentage of head DNA and an increase in the percentage of tail DNA. The most striking tail formation among the Mtz-treated groups was observed in the group receiving 500 mg/kg Mtz. In the presence of Mtz, there was a hypochromic shift in the absorption spectrum of DNA, and the potential DNA-Mtz interaction was found to occur in the intercalation mode. These results show that Mtz used against anaerobic bacteria and protozoa in gastrointestinal infections can cause severe cardiotoxic findings in albino mice and cause fragmentation in DNA.
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Affiliation(s)
- Fatmanur Coşkun
- Department of Biology, Institute of Science, Giresun University, Giresun, Turkiye.
| | - Emine Yalçın
- Department of Biology, Faculty of Science and Art, Giresun University, Giresun, Turkiye.
| | - Kültiğin Çavuşoğlu
- Department of Biology, Faculty of Science and Art, Giresun University, Giresun, Turkiye.
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9
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Takahashi K, Tomidokoro Y, Oda T. Metronidazole-induced encephalopathy after living donor liver transplantation. Transpl Infect Dis 2024; 26:e14240. [PMID: 38265157 DOI: 10.1111/tid.14240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 01/02/2024] [Indexed: 01/25/2024]
Affiliation(s)
- Kazuhiro Takahashi
- Department of Gastrointestinal and Hepatobiliary-Pancreatic Surgery, University of Tsukuba, Tsukuba, Japan
| | | | - Tatsuya Oda
- Department of Gastrointestinal and Hepatobiliary-Pancreatic Surgery, University of Tsukuba, Tsukuba, Japan
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10
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Li H, Yasheng A, Maimaiti T, Mahat N, Wang Z. Metronidazole-induced Encephalopathy. Neurol India 2024; 72:204. [PMID: 38443042 DOI: 10.4103/neurol-india.neurol-india-d-23-00690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/02/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Hongmei Li
- Department of Neurology, Kashi Prefecture Second People's Hospital; XinJiang, China
| | | | - Talifujiang Maimaiti
- Department of Neurology, Kashi Prefecture Second People's Hospital; XinJiang, China
| | - Nurahmat Mahat
- Department of Neurology, Kashi Prefecture Second People's Hospital; XinJiang, China
| | - Zigao Wang
- Department of Neurology, Kashi Prefecture Second People's Hospital; XinJiang, China
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
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11
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Ji X, Li KX, Freitas LF, Huot P. Metronidazole-induced encephalopathy in a patient with cirrhosis. Radiol Case Rep 2024; 19:126-129. [PMID: 37941988 PMCID: PMC10628797 DOI: 10.1016/j.radcr.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/01/2023] [Accepted: 10/01/2023] [Indexed: 11/10/2023] Open
Abstract
Metronidazole is a commonly used antibiotic with anaerobic bacterial, protozoal, and microaerophilic bacterial coverage. Encephalopathy and peripheral neurotoxicity are rare but known adverse events with prolonged metronidazole use, which can be difficult to distinguish from other causes of delirium in acutely ill patients. Definitive diagnosis can be made by brain magnetic resonance imaging (MRI), which often reveals symmetric bilateral hypersignal demyelination lesions typically involving the dentate nuclei, splenium of the corpus collosum, midbrain, dorsal medulla, and pons. This case report describes a 72-year-old male presenting with altered mental status and neurological deficits after prolonged metronidazole use for bacteremia with spondylodiscitis, with full clinical and neuroradiological resolution upon appropriate diagnosis and drug cessation. Neuroradiologists play an indispensable role in recognizing this rare and poorly understood manifestation.
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Affiliation(s)
- Xinyu Ji
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Ke Xuan Li
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Leonardo Furtado Freitas
- Department of Diagnostic Radiology, Clinical Neuroradiology Fellow, McGill University, Montreal, QC, Canada
| | - Philippe Huot
- Neurodegenerative Disease Group, Montreal Neurological Institute-Hospital (The Neuro), Montreal, QC, Canada
- Department of Neurology & Neurosurgery, McGill University, Montreal, QC, Canada
- Movement Disorder Clinic, Division of Neurology, Department of Neuroscience, McGill University Health Centre, Montreal, QC, Canada
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12
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Mo S, Thursky K, Chronas A, Hall L, James R, Ierano C. Metronidazole prescribing practices in Australian hospitals: Measuring guideline compliance and appropriateness to support antimicrobial stewardship. J Infect Public Health 2023; 16 Suppl 1:90-96. [PMID: 37926594 DOI: 10.1016/j.jiph.2023.10.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 10/25/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Metronidazole is a commonly prescribed antimicrobial in Australian hospitals. Inappropriate use may increase risks to patient care, such as toxicities and antimicrobial resistance. To date, there is limited information on the quality of metronidazole prescriptions to inform antimicrobial stewardship and quality improvement initiatives. This study aims to describe the quality of metronidazole prescribing practices in Australian hospitals. METHODS Retrospective data analysis of the Hospital National Antimicrobial Prescribing Survey (Hospital NAPS). Data were collected by auditors at each participating hospital using a standardised auditing tool. All data from 2013 to 2021 were de-identified and analysed descriptively. Variables included were antimicrobial prescribed, indication, guideline compliance and appropriateness. RESULTS Metronidazole was the fifth most prescribed antimicrobial in the Hospital NAPS dataset (2013-2021), accounting for 5.7 % (n = 14,197) of all antimicrobial prescriptions (n = 250,863). The proportion of metronidazole prescriptions declined by 2 % from 2013 to 2021 (p < 0.001). The most common indications were surgical prophylaxis (15.3 %), diverticulitis (9.4 %), aspiration pneumonia (7.3 %). Over half (53.5 %) of metronidazole prescriptions were deemed compliant with prescribing guidelines and 67.8 % were deemed appropriate. These rates were comparatively lower than the overall results of all antimicrobials. The primary documented reason for inappropriateness was that the spectrum was too broad (34.2 %). Surgical prophylaxis had the lowest rates of guideline compliance (53.8 %) and appropriateness (54.3 %). CONCLUSIONS Metronidazole remains widely used in Australian hospitals with suboptimal rates of guideline compliance and appropriateness. A noted area for improvement that we identified was using metronidazole when its spectrum was too broad, possibly when anaerobic therapy is unnecessary. With increasing international adoption of the Hospital NAPS programme, future comparative studies will be critical to identify global trends of antimicrobial prescribing quality. Antimicrobial stewardship (AMS) programmes have proven to be effective in improving prescribing quality and should be considered to specifically target improvements in metronidazole prescribing.
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Affiliation(s)
- Simone Mo
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, 300 Grattan St, Parkville, Victoria, Australia
| | - Karin Thursky
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Victoria, Australia; Royal Melbourne Hospital Guidance Group, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Australia
| | - Alexandros Chronas
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, 300 Grattan St, Parkville, Victoria, Australia
| | - Lisa Hall
- Royal Melbourne Hospital Guidance Group, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Australia; School of Public Health, The University of Queensland, 266 Herston Rd, Herston, Queensland, Australia
| | - Rodney James
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Victoria, Australia; Royal Melbourne Hospital Guidance Group, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Australia
| | - Courtney Ierano
- National Centre for Antimicrobial Stewardship, Department of Infectious Diseases, University of Melbourne, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Victoria, Australia; Royal Melbourne Hospital Guidance Group, Royal Melbourne Hospital, Peter Doherty Institute for Infection and Immunity, 792 Elizabeth Street, Melbourne, Australia.
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13
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Hafez G, Malyszko J, Golenia A, Klimkowicz-Mrowiec A, Ferreira AC, Arıcı M, Bruchfeld A, Nitsch D, Massy ZA, Pépin M, Capasso G, Mani LY, Liabeuf S. Drugs with a negative impact on cognitive functions (Part 2): drug classes to consider while prescribing in CKD patients. Clin Kidney J 2023; 16:2378-2392. [PMID: 38046029 PMCID: PMC10689198 DOI: 10.1093/ckj/sfad239] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Indexed: 12/05/2023] Open
Abstract
There is growing evidence that chronic kidney disease (CKD) is an independent risk factor for cognitive impairment, especially due to vascular damage, blood-brain barrier disruption and uremic toxins. Given the presence of multiple comorbidities, the medication regimen of CKD patients often becomes very complex. Several medications such as psychotropic agents, drugs with anticholinergic properties, GABAergic drugs, opioids, corticosteroids, antibiotics and others have been linked to negative effects on cognition. These drugs are frequently included in the treatment regimen of CKD patients. The first review of this series described how CKD could represent a risk factor for adverse drug reactions affecting the central nervous system. This second review will describe some of the most common medications associated with cognitive impairment (in the general population and in CKD) and describe their effects.
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Affiliation(s)
- Gaye Hafez
- Department of Pharmacology, Faculty of Pharmacy, Altinbas University, Istanbul, Turkey
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | | | | | - Ana Carina Ferreira
- Nephrology Department, Centro Hospitalar e Universitário de Lisboa Central, Lisbon, Portugal
- Universidade Nova de Lisboa-Faculdade de Ciências Médicas-Nephology, Lisbon, Portugal
| | - Mustafa Arıcı
- Department of Internal Medicine, Division of Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Ziad A Massy
- Paris-Saclay University, UVSQ, Inserm, Clinical Epidemiology Team, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Villejuif, France
- Department of Nephrology, Ambroise Paré University Medical Center, APHP, Paris, France
| | - Marion Pépin
- Department of Nephrology, Ambroise Paré University Medical Center, APHP, Paris, France
- Department of Geriatrics, Ambroise Paré University Medical Center, APHP, Boulogne-Billancourt, France
| | - Giovambattista Capasso
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
- Biogem Research Institute, Ariano Irpino, Italy
| | - Laila-Yasmin Mani
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sophie Liabeuf
- Pharmacoepidemiology Unit, Department of Clinical Pharmacology, Amiens University Medical Center, Amiens, France
- MP3CV Laboratory, EA7517, Jules Verne University of Picardie, Amiens, France
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14
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Yoon HJ, Lee JH, Lee SU, Kim JS. Metronidazole-induced cerebellar dysfunction preferentially involving the saccadic system. J Neurol 2023; 270:6166-6169. [PMID: 37688634 DOI: 10.1007/s00415-023-11972-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/11/2023]
Affiliation(s)
- Ho-Jin Yoon
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-Ro, Seongbuk-Gu, Seoul, 02841, South Korea
| | - Joo-Hyeong Lee
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-Ro, Seongbuk-Gu, Seoul, 02841, South Korea
- Neurotology and Neuro-Ophthalmology Laboratory, Korea University Anam Hospital, Seoul, South Korea
| | - Sun-Uk Lee
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-Ro, Seongbuk-Gu, Seoul, 02841, South Korea.
- Neurotology and Neuro-Ophthalmology Laboratory, Korea University Anam Hospital, Seoul, South Korea.
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
- Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea
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15
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Fearon C, Sundaram AE, Munhoz RP, Fasano A, Tyndel F. Downbeat Nystagmus in Metronidazole Neurotoxicity. Can J Neurol Sci 2023; 50:941-943. [PMID: 36451594 DOI: 10.1017/cjn.2022.330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
- Conor Fearon
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, UHN-Toronto Western Hospital, Canada
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
- Mater Misericordiae University Hospital, University College Dublin, Ireland
| | - Arun E Sundaram
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Renato P Munhoz
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, UHN-Toronto Western Hospital, Canada
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
- Neuromodulation Unit and Ataxia Clinic, Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, UHN-Toronto Western Hospital, Canada
- Krembil Brain Institute, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, UHN-Toronto Western Hospital, Canada
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
- Krembil Brain Institute, Toronto, Ontario, Canada
| | - Felix Tyndel
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
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16
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Hayer SS, Hwang S, Clayton JB. Antibiotic-induced gut dysbiosis and cognitive, emotional, and behavioral changes in rodents: a systematic review and meta-analysis. Front Neurosci 2023; 17:1237177. [PMID: 37719161 PMCID: PMC10504664 DOI: 10.3389/fnins.2023.1237177] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/18/2023] [Indexed: 09/19/2023] Open
Abstract
There are previous epidemiological studies reporting associations between antibiotic use and psychiatric symptoms. Antibiotic-induced gut dysbiosis and alteration of microbiota-gut-brain axis communication has been proposed to play a role in this association. In this systematic review and meta-analysis, we reviewed published articles that have presented results on changes in cognition, emotion, and behavior in rodents (rats and mice) after antibiotic-induced gut dysbiosis. We searched three databases-PubMed, Web of Science, and SCOPUS to identify such articles using dedicated search strings and extracted data from 48 articles. Increase in anxiety and depression-like behavior was reported in 32.7 and 40.7 percent of the study-populations, respectively. Decrease in sociability, social novelty preference, recognition memory and spatial cognition was found in 18.1, 35.3, 26.1, and 62.5 percent of the study-populations, respectively. Only one bacterial taxon (increase in gut Proteobacteria) showed statistically significant association with behavioral changes (increase in anxiety). There were no consistent findings with statistical significance for the potential biomarkers [Brain-derived neurotrophic factor (BDNF) expression in the hippocampus, serum corticosterone and circulating IL-6 and IL-1β levels]. Results of the meta-analysis revealed a significant association between symptoms of negative valence system (including anxiety and depression) and cognitive system (decreased spatial cognition) with antibiotic intake (p < 0.05). However, between-study heterogeneity and publication bias were statistically significant (p < 0.05). Risk of bias was evaluated to be high in the majority of the studies. We identified and discussed several reasons that could contribute to the heterogeneity between the results of the studies examined. The results of the meta-analysis provide promising evidence that there is indeed an association between antibiotic-induced gut dysbiosis and psychopathologies. However, inconsistencies in the implemented methodologies make generalizing these results difficult. Gut microbiota depletion using antibiotics may be a useful strategy to evaluate if and how gut microbes influence cognition, emotion, and behavior, but the heterogeneity in methodologies used precludes any definitive interpretations for a translational impact on clinical practice.
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Affiliation(s)
- Shivdeep S. Hayer
- Department of Biology, University of Nebraska at Omaha, Omaha, NE, United States
- Callitrichid Research Center, University of Nebraska at Omaha, Omaha, NE, United States
- Nebraska Food for Health Center, University of Nebraska-Lincoln, Lincoln, NE, United States
- Department of Population Medicine, University of Guelph, Guelph, ON, Canada
| | - Soonjo Hwang
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, NE, United States
| | - Jonathan B. Clayton
- Department of Biology, University of Nebraska at Omaha, Omaha, NE, United States
- Callitrichid Research Center, University of Nebraska at Omaha, Omaha, NE, United States
- Nebraska Food for Health Center, University of Nebraska-Lincoln, Lincoln, NE, United States
- Department of Food Science and Technology, University of Nebraska-Lincoln, Lincoln, NE, United States
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, NE, United States
- Primate Microbiome Project, University of Nebraska-Lincoln, Lincoln, NE, United States
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17
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El-Moslemany AM, Abd-Elfatah MH, Tahoon NA, Bahnasy RM, Alotaibi BS, Ghamry HI, Shukry M. Mechanistic Assessment of Anise Seeds and Clove Buds against the Neurotoxicity Caused by Metronidazole in Rats: Possible Role of Antioxidants, Neurotransmitters, and Cytokines. TOXICS 2023; 11:724. [PMID: 37755735 PMCID: PMC10538152 DOI: 10.3390/toxics11090724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/28/2023]
Abstract
Long-term use of the nitroimidazole-derived antibiotic metronidazole has been associated with neuronal damage due to its ability to cross the blood-brain barrier. Polyphenol-rich plants, such as anise seeds and clove buds, are suggested to have neuroprotective effects. However, their intracellular protective pathway against metronidazole-induced neurotoxicity remains unexplored. This study aims to evaluate the potential neuroprotective benefits of anise seeds and clove buds and elucidate the proposed metronidazole-induced neurotoxicity mechanism. This study divided rats into six groups, each containing six rats. In Group I, the control group, rats were administered saline orally. Group II rats received 200 mg/kg of metronidazole orally. Group III rats received 250 mg/kg b.w. of anise seed extract and metronidazole. Group IV rats received 500 mg/kg b.w. of anise seed extract (administered orally) and metronidazole. Group V rats received 250 mg/kg b.w. of clove bud extract (administered orally) and metronidazole. Group VI rats were administered 500 mg/kg b.w. of clove bud extract and metronidazole daily for 30 consecutive days. The study evaluated the phenolic compounds of anise seeds and clove buds. Moreover, it assessed the inflammatory and antioxidant indicators and neurotransmitter activity in brain tissues. A histological examination of the brain tissues was conducted to identify neuronal degeneration, brain antioxidants, and apoptotic mRNA expression. The study found that metronidazole treatment significantly altered antioxidant levels, inflammatory mediators, and structural changes in brain tissue. Metronidazole also induced apoptosis in brain tissue and escalated the levels of inflammatory cytokines. Oral administration of metronidazole resulted in a decrease in GABA, dopamine, and serotonin and an increase in ACHE in brain tissue. Conversely, oral administration of anise and clove extracts mitigated the harmful effects of metronidazole. The neurotoxic effects of metronidazole appear to stem from its ability to reduce antioxidants in brain tissue and increase nitric oxide production and apoptosis. The study concludes that neuronal damage caused by metronidazole is significantly mitigated by treatment with anise and clove extracts.
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Affiliation(s)
- Amira M. El-Moslemany
- Nutrition and Food Science Department, Faculty of Home Economics, Al-Azhar University, Tanta 31732, Egypt; (A.M.E.-M.); (R.M.B.)
| | - Mai Hussein Abd-Elfatah
- Nutrition and Food Science Department, Faculty of Home Economics, Al-Azhar University, Tanta 31732, Egypt; (A.M.E.-M.); (R.M.B.)
| | - Nawal A. Tahoon
- Department of Home Economics, Faculty of Specific Education, Banha University, Banha 13511, Egypt;
| | - Rasha M. Bahnasy
- Nutrition and Food Science Department, Faculty of Home Economics, Al-Azhar University, Tanta 31732, Egypt; (A.M.E.-M.); (R.M.B.)
| | - Badriyah S. Alotaibi
- Department of Pharmaceutical Sciences, College of Pharmacy, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia
| | - Heba I. Ghamry
- Nutrition and Food Sciences, Department of Home Economics, Faculty of Home Economics, King Khalid University, P.O. Box 960, Abha 61421, Saudi Arabia;
| | - Mustafa Shukry
- Physiology Department, Faculty of Veterinary Medicine, Kafrelsheikh University, Kafrelsheikh 33516, Egypt
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18
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Justich MB, Rojas OL, Fasano A. The Role of Helicobacter pylori and Small Intestinal Bacterial Overgrowth in Parkinson's Disease. Semin Neurol 2023; 43:553-561. [PMID: 37562451 DOI: 10.1055/s-0043-1771468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Parkinson's disease (PD) is a common neurodegenerative disorder whose etiology remains largely unexplained. Several studies have aimed to describe a causative effect in the interactions between the gastrointestinal tract and the brain, for both PD pathogenesis and disease course. However, the results have been controversial. Helicobacter pylori and small intestinal bacterial overgrowth (SIBO) are theorized to be agents capable of triggering chronic proinflammatory changes with a possible neurotoxic effect, as well as a cause of erratic L-dopa response in PD patients. This review evaluates the individual and possibly synergistic influence of H. pylori and SIBO on PD, to provide an opportunity to consider prospective therapeutic approaches.
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Affiliation(s)
- Maria Belen Justich
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Olga L Rojas
- Krembil Brain Institute, University Health Network, Toronto, Ontario, Canada
- Department of Immunology, University of Toronto, Ontario, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
- Department of Parkinson's Disease and Movement Disorders Rehabilitation, Moriggia-Pelascini Hospital - Gravedona ed Uniti, Como, Italy
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19
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Shea YF, Lee CMY, Ip WCT, Luk DWA, Wong SSW. Use of GPT-4 to Analyze Medical Records of Patients With Extensive Investigations and Delayed Diagnosis. JAMA Netw Open 2023; 6:e2325000. [PMID: 37578798 PMCID: PMC10425828 DOI: 10.1001/jamanetworkopen.2023.25000] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/08/2023] [Indexed: 08/15/2023] Open
Abstract
This case series investigates whether analysis of clinical history via a language model system improves diagnostic accuracy in patients with complex and delayed diagnoses.
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Affiliation(s)
- Yat-Fung Shea
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Cynthia Min Yao Lee
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
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20
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Tauber SC, Nau R. Treatment of septic encephalopathy and encephalitis - a critical appraisal. Expert Rev Neurother 2023; 23:1069-1080. [PMID: 38019041 DOI: 10.1080/14737175.2023.2288652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/23/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION The central nervous system is frequently involved during severe sepsis. Patients either develop septic encephalopathy characterized by delirium and coma or focal neurological signs as a consequence of septic-embolic or septic-metastatic encephalitis. AREAS COVERED In this review, a summary of currently available literature on established and some promising experimental treatment options for septic encephalopathy and encephalitis is provided, with a focus on the clinical utility of published studies. EXPERT OPINION Treatment relies on proper identification of the causative pathogen and rapidly initiated adequate empirical or (after identification of the pathogen) tailored antibiotic therapy, fluid and electrolyte management. In the presence of brain abscess(es) or mycotic aneurysm(s), surgery or interventional neuroradiology must be considered. Pharmacological approaches to prevent delirium of different etiology include the use of dexmedetomidine and (with limitations) of melatonin and its derivatives. In the absence of a specific pharmacological treatment, non-pharmacological bundles of interventions (e.g. promotion of sleep, cognitive stimulation, early mobilization and adequate therapy of pain) are of proven efficacy to prevent delirium of different etiology including sepsis. Experimental promising therapies include the use of non-bacteriolytic antibiotics and the reduction of the toxic effects of microglial activation.
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Affiliation(s)
- Simone C Tauber
- Department of Neurology, RWTH University Hospital Aachen, Aachen, Germany
| | - Roland Nau
- Department of Neuropathology, University Medicine Göttingen, Georg-August-University Göttingen, Göttingen, Germany
- Department of Geriatrics, Evangelisches Krankenhaus Göttingen-Weende, Göttingen, Germany
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21
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Gong Y, Zhai K, Sun L, He L, Wang H, Guo Y, Zhang J. RdxA Diversity and Mutations Associated with Metronidazole Resistance of Helicobacter pylori. Microbiol Spectr 2023; 11:e0390322. [PMID: 36943041 PMCID: PMC10100817 DOI: 10.1128/spectrum.03903-22] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 02/15/2023] [Indexed: 03/23/2023] Open
Abstract
Metronidazole (MNZ) is administered as first-line antibiotic for Helicobacter pylori eradication therapy; however, increasing resistance to MNZ impaired the efficacy. Increasing the dose of MNZ was recommended to overcome low-level resistance, but it was difficult to determine MNZ resistance level simply based on the rdxA gene mutation. In this study, the rdxA sequences of 511 clinical H. pylori strains were analyzed to assess the genotypes associated with MNZ resistance. We observed that the prevalences of rdxA sequences with missense, nonsense, and frameshift mutations were 70.25, 11.35, and 17.03%, respectively. Regarding the amino acid substitutions, T31E, H53R, D59N, L62V, S88P, G98S/N, R131K, and V172I were present in most strains regardless of the resistance phenotype. The correlation analysis showed R16H/C, Y47C, A67V/T, and V204I substitutions were associated with MNZ resistance. The mutation resulting in RdxA truncation was observed in 36.29% of the resistant strains, and 83.45% of these strains displayed high-level MNZ resistance (MIC > 256 μg/mL). Moreover, all strains with truncated mutation positions before amino acid 70 expressed high-level MNZ resistance. Our results indicated that most amino acid mutations probably contributed to the sequence diversity of RdxA, while R16H/C, Y47C, A67V/T, and V204I were potentially helpful to identify resistant strains. Although it was difficult to determine the mutations associated with MNZ resistance, the prediction of high-level resistance based on truncated characteristics of RdxA might be an important approach, which can effectively avoid H. pylori eradication therapy with unreasonable of MNZ dose increases for patients with high-level drug resistance. IMPORTANCE The increasing resistance to metronidazole impaired the efficacy of Helicobacter pylori eradication, and increasing the dose of metronidazole was recommended to overcome low-level resistance. For patients infected with highly resistant strains, the current empirical treatments, which generally used metronidazole in double doses or more, appeared impossibly to overcome the resistance and would only increase the incidence of adverse effects. Our results indicated that high-level metronidazole resistance was predominant, and almost half of the patients with high-level drug resistance could avoid usage of metronidazole based on the truncated mutations of RdxA sequences, which can effectively avoid H. pylori eradication therapy with unreasonable increases in the metronidazole dose.
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Affiliation(s)
- Yanan Gong
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Kangle Zhai
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Lu Sun
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Lihua He
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Hairui Wang
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yahui Guo
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jianzhong Zhang
- State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
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22
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Hosaka T, Terada M, Okubo K, Iwabuchi S, Kajii E. Management of a rare case of metronidazole-induced encephalopathy presenting as posterior reversible encephalopathy syndrome: a case report. Neurol Sci 2023; 44:1101-1103. [PMID: 36322211 DOI: 10.1007/s10072-022-06480-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/27/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Takashi Hosaka
- Ibaraki Western Medical Center, University of Tsukuba Hospital/Jichi Medical University Joint Ibaraki Western Regional Clinical Education Center, Chikusei, Ibaraki, Japan.
- Department of Internal Medicine, Ibaraki Western Medical Center, Chikusei, Ibaraki, Japan.
- Department of Neurology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan.
| | - Makoto Terada
- Ibaraki Western Medical Center, University of Tsukuba Hospital/Jichi Medical University Joint Ibaraki Western Regional Clinical Education Center, Chikusei, Ibaraki, Japan
- Department of Internal Medicine, Ibaraki Western Medical Center, Chikusei, Ibaraki, Japan
- Department of Neurology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Katsuichiro Okubo
- Department of Internal Medicine, Ibaraki Western Medical Center, Chikusei, Ibaraki, Japan
| | - Satoshi Iwabuchi
- Department of Internal Medicine, Ibaraki Western Medical Center, Chikusei, Ibaraki, Japan
| | - Eiji Kajii
- Ibaraki Western Medical Center, University of Tsukuba Hospital/Jichi Medical University Joint Ibaraki Western Regional Clinical Education Center, Chikusei, Ibaraki, Japan
- Department of Internal Medicine, Ibaraki Western Medical Center, Chikusei, Ibaraki, Japan
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Cha S, Lee BC, Moon CW, Cho KH. Metronidazole-induced encephalopathy delayed diagnosis due to cerebellar infarction: A case report. Medicine (Baltimore) 2023; 102:e32788. [PMID: 36749268 PMCID: PMC9902015 DOI: 10.1097/md.0000000000032788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
RATIONALE Metronidazole is a 5-nitroimidazole antibiotic effective against anaerobic bacterial and parasitic infections. Long-term use may cause side effects in the central nervous system, although the occurrence of encephalopathy is rare. PATIENT CONCERNS A 73-year-old man was diagnosed with acute pyelonephritis and received antibiotic treatment. During the treatment, the patient complained of back pain. Lumbar spinal magnetic resonance imaging (MRI) revealed infective spondylitis, and metronidazole (1.5 g) was administered daily for approximately 160 days. The patient developed cognitive dysfunction and gait disorder after antibiotic treatment, and brain MRI showed acute infarction in both cerebellar lobes. Secondary prevention with antiplatelet and physiotherapy was prescribed; however, functional recovery was not achieved. DIAGNOSIS After 1 month, a follow-up brain MRI showed high signal intensity and diffusion restriction in the corpus callosum on diffusion-weighted images and high signal intensity in the dentate nucleus on T2-weighted images. Therefore, metronidazole-induced encephalopathy was suspected. INTERVENTIONS Metronidazole was discontinued, and ceftriaxone (2 g/day) was administered to manage the infective spondylitis. OUTCOMES One week after the discontinuation of the drug, the patient's cognition improved to the extent that communication was possible. Thus, even if other neurological deficits, such as cerebellar infarction, are found in patients with long-term disability, the possibility of metronidazole-induced encephalopathy should be considered when metronidazole is used for a long time.
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Affiliation(s)
- Sangha Cha
- Department of Rehabilitation Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Byung Chan Lee
- Department of Rehabilitation Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
| | - Chang-Won Moon
- Department of Rehabilitation Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
- Department of Biomedical Institute, Chungnam National University, Daejeon, Korea
| | - Kang Hee Cho
- Department of Rehabilitation Medicine, School of Medicine, Chungnam National University, Daejeon, Korea
- Department of Biomedical Institute, Chungnam National University, Daejeon, Korea
- * Correspondence: Kang Hee Cho, Department of Rehabilitation Medicine, School of Medicine, Chungnam National University, Daejeon 35015, Korea (e-mail: )
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Huang YT, Sun CY, Chang CM, Lai CC. Metronidazole-induced encephalopathy: Uncommon cause of recurrent falling in a geriatric man. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:203-205. [PMID: 36210316 DOI: 10.1016/j.jmii.2022.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/20/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Yi-Te Huang
- Department of Geriatrics and Gerontology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chien-Yao Sun
- Department of Geriatrics and Gerontology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Chia-Ming Chang
- Department of Geriatrics and Gerontology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Cheng Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Tainan, Taiwan
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25
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Dos Anjos MV, Bergoza L, Fonseca G, Possa E, Dos Santos P, Moura E Silva S, Tasso L. Fast determination of free metronidazole in rat plasma and peritoneal fluid using HPLC-UV method. Biomed Chromatogr 2023; 37:e5543. [PMID: 36336463 DOI: 10.1002/bmc.5543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022]
Abstract
Peritonitis refers to the inflammatory reaction of the peritoneum to aggression. In addition, it contributes significantly to sepsis. The presence of free concentrations of antimicrobials above the minimum inhibitory concentration at the site of infection is critical to therapeutic response. Metronidazole (MTZ) is an antimicrobial used to treat peritonitis because of its effectiveness against anaerobic microorganisms. This study investigates free MTZ concentrations in peritoneal microdialysate in Wistar rats. A C18 column (150 × 4.0 mm, 5 μm) was used for the analysis conducted at 40°C under isocratic conditions. The mobile phase consisted of acetonitrile and an aqueous solution of 50-mM monobasic phosphate buffer and 0.1% triethylamine, with pH 3.0 (10:90, v/v). MTZ calibration was linear in the range of 0.5-30.0 μg/ml. The intra- and inter-day precision was satisfactory with relative standard deviation ≤5.67%. The accuracy ranged from 90.64 to 103.77%, and the lower limit of quantification was 0.5 μg/ml. The developed method was successfully applied in a pilot pharmacokinetic study after MTZ administration (30 mg/kg, intravenously) in rats. The main advantage of the employed method is that it does not require sample processing and protein removal steps. This is the first study to be conducted using MTZ in rats.
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26
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Hirani R, Harutyunyan A, Smiley A. Burden of antibiotics in patients with uncomplicated diverticulitis. Surgery 2023; 173:555. [PMID: 35660023 DOI: 10.1016/j.surg.2022.04.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/29/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Rahim Hirani
- New York Medical College School of Medicine and Department of Surgery, Westchester Medical Center, Valhalla, New York.
| | - Aleksandr Harutyunyan
- New York Medical College School of Medicine and Department of Surgery, Westchester Medical Center, Valhalla, New York
| | - Abbas Smiley
- New York Medical College School of Medicine and Department of Surgery, Westchester Medical Center, Valhalla, New York
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27
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Salem A, Lewis W, Kania B, Yucel D, Kahf MY, Millet C. Metronidazole induced cerebellar toxicity after prolonged treatment of large multiloculated pyogenic liver abscess; A case report and literature review. IDCases 2023; 31:e01683. [PMID: 36704028 PMCID: PMC9871297 DOI: 10.1016/j.idcr.2023.e01683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 01/03/2023] [Accepted: 01/06/2023] [Indexed: 01/14/2023] Open
Abstract
Metronidazole is a common antibiotic agent for hepatic abscesses, which require both gram-negative and anaerobic coverage. Rarely, this antibiotic has been found to induce encephalopathy. Here, we describe a 65-year-old male who was treated with metronidazole for his hepatic abscess, who presented with syncope and questionable seizure and was found to have magnetic resonance imaging (MRI) brain findings consistent with metronidazole toxicity. Our patient demonstrated striking brain MRI findings which can be used to further understand the process behind this medication-induced toxicity. Hypotheses of this mechanism include swelling of axons secondary to increased water or vasospasm leading to reversible ischemia that is localized in the brain. In terms of MRI findings, brain lesions tend to populate bilaterally with focus at the dorsal pons, midbrain, cerebellar dentate nuclei (as with our patient), dorsal medulla, or splenium of corpus callosum. Additional research is warranted regarding this rare manifestation and timely removal of the offending agent is crucial for reversal of symptoms.
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Affiliation(s)
- Ahmed Salem
- Correspondence to: Internal Medicine Resident, Saint Joseph University Medical Center, 703 Main Street, Paterson, NJ 07503, USA.
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Correlation of magnetic resonance images with neuropathology of irreversible metronidazole-induced encephalopathy: an autopsy case report. BMC Neurol 2022; 22:485. [PMID: 36522715 PMCID: PMC9753291 DOI: 10.1186/s12883-022-03006-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 12/03/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Neurological symptoms and radiographic abnormalities may remain in a small proportion of patients with metronidazole-induced encephalopathy (MIE). Although experimental animal models of MIE have suggested a Wernicke's encephalopathy-like pathology, little is known about the histopathological features of MIE. Here we report the first autopsy case of irreversible MIE. CASE PRESENTATION A 72-year-old Japanese woman with pancreatic neuroendocrine tumour and metastatic tumours in the liver developed intraabdominal bleeding from a hepatic abscess. She was administered metronidazole for 79 days (1.5 g/day), which caused dysarthria followed by hand tremor and altered mental status. Brain magnetic resonance imaging at the time of onset revealed hyperintensities in the deep white matter of the bilateral parietal lobes and splenium of the corpus callosum on diffusion-weighted imaging (DWI) with reduced apparent diffusion coefficient (ADC) values. Despite the improvement of dysarthria and hand tremor, her cognition remained affected even after the withdrawal of metronidazole. She died of pancreatic neuroendocrine tumour at the age of 74 years. Histopathological examinations of the brain confirmed a combination of severe demyelination and moderate axonal degeneration, which corresponded to the regions showing abnormal signal intensities on DWI with reduced ADC values. There were no pathological findings suggestive of Wernicke's encephalopathy in the brain. CONCLUSION We have demonstrated the clinical, radiographic and histopathological aspects of irreversible MIE. Hyperintensities on DWI with reduced ADC values in affected regions may indicate a poor clinical prognosis due to irreversible pathological damage.
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Rybak K, Warchoł A, Drobczyński Ł, Banaszkiewicz A. Metronidazole-Induced Encephalopathy in a 16-Year-Old Girl with Crohn’s Disease: Case Report and Review of the Pediatric Literature. CHILDREN 2022; 9:children9091408. [PMID: 36138717 PMCID: PMC9497710 DOI: 10.3390/children9091408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 11/29/2022]
Abstract
Metronidazole-induced encephalopathy (MIE) is a rare and unpredictable complication that is most commonly reported in adults. Here, we present the case of MIE in a patient treated with rectal, oral, and intravenous metronidazole. This is the first case of MIE reported after suppositories. A 16-year-old girl with Crohn’s disease treated with mesalazine and exclusive enteral nutrition was operated on due to perianal fistulas and abscesses. She received oral metronidazole for 25 days and rectal metronidazole for 15 days as an adjuvant before surgery. Moreover, 2.5 g of intravenous metronidazole was administrated during the perioperative period. The second day after the surgery, symptoms of cerebellar syndrome appeared. She presented with an inability to coordinate balance and gait. Although she showed accurate verbal responses, her speech was slow, slurred, and scanning. The finger–nose test was positive. The T2-weighted magnetic resonance imaging revealed an increased symmetrical signal within the dentate nuclei of the cerebellum and in the corpus callosum. The changes were characterized by restricted diffusion. Based on the clinical picture and magnetic resonance imaging findings, MIE was diagnosed. Treatment with metronidazole was discontinued. The cumulative dose of metronidazole that she received for 29 days was 54 g: 38 g p.o., 13.5 g p.r., and 2.5 g i,v. The first symptoms appeared on the 28th day of antibiotic therapy after receiving 52 g of metronidazole. The neurological symptoms resolved after six days; however, three days after the resolution, paresthesia appeared in the distal phalanges of both feet and lasted for approximately two months. Our report highlights that neurologic symptoms related to metronidazole treatment should raise the suspicion of MIE.
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Affiliation(s)
- Karolina Rybak
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, 02-091 Warsaw, Poland
- Correspondence:
| | - Aleksandra Warchoł
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Łukasz Drobczyński
- Department of Pediatric Radiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Aleksandra Banaszkiewicz
- Department of Pediatric Gastroenterology and Nutrition, Medical University of Warsaw, 02-091 Warsaw, Poland
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30
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Pierce ES, Barkhaus P, Beauchamp M, Bromberg M, Carter GT, Goslinga J, Greeley D, Kihuwa-Mani S, Levitsky G, Lund I, McDermott C, Pattee G, Pierce K, Polak M, Ratner D, Wicks P, Bedlack R. ALSUntangled #66: antimycobacterial antibiotics. Amyotroph Lateral Scler Frontotemporal Degener 2022:1-5. [PMID: 35913017 DOI: 10.1080/21678421.2022.2104650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Several infections have been associated with motor neuron diseases resembling ALS, including species of viruses, bacteria, and parasites. Mycobacterium avium subspecies paratuberculosis (MAP), most known for its probable etiologic association with Crohn's disease, has been suggested as another possible infectious cause of motor neuron disease. Two published case reports describe the successful treatment of ALS-like symptoms with antimycobacterial antibiotics. Both cases had atypical features. Based on these, we believe it would be reasonable to begin performing chest imaging in PALS who have features of their history or exam that are atypical for ALS such as pain, fevers, or eye movement abnormalities. If the chest imaging is abnormal, more specific testing for mycobacteria may be indicated. Until there is more clear evidence of an association between mycobacteria and ALS, we cannot endorse the widespread use of potentially toxic antimycobacterial antibiotics for PALS.
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Affiliation(s)
| | - Paul Barkhaus
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Morgan Beauchamp
- UNC Neurosciences Clinical Trials Unit, University of North Carolina, Chapel Hill, NC, USA
| | - Mark Bromberg
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Gregory T Carter
- Department of Rehabilitation, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Jill Goslinga
- Department of Neurology, University of California, San Francisco, CA, USA
| | - David Greeley
- Northwest Neurological Associates, PLLC, Spokane, WA, USA
| | | | | | - Isaac Lund
- Undergraduate, Green Hope High School, Cary, NC, USA
| | | | - Gary Pattee
- Department of Neurology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kaitlyn Pierce
- Department of Neuroscience, University of North Carolina, Chapel Hill, NC, USA
| | - Meraida Polak
- Department of Neurology, Emory University School of Medicine, Emory, GA, USA
| | - Dylan Ratner
- Undergraduate, Longmeadow High School, Longmeadow, MA, USA
| | - Paul Wicks
- Independent Consultant, Lichfield, England, UK
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31
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Li XL, Zhao HT, Han J, Yan ZR, Wang HY. Toxic encephalopathy induced by radix Sophorae tonkinensis. Acta Neurol Belg 2022; 122:855-858. [PMID: 33417151 DOI: 10.1007/s13760-020-01587-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
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Krakovka S, Ranjbarian F, Luján LA, Saura A, Larsen NB, Jiménez-González A, Reggenti A, Luján HD, Svärd SG, Hofer A. Giardia intestinalis thymidine kinase is a high-affinity enzyme crucial for DNA synthesis and an exploitable target for drug discovery. J Biol Chem 2022; 298:102028. [PMID: 35568200 PMCID: PMC9190010 DOI: 10.1016/j.jbc.2022.102028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/06/2022] [Accepted: 05/07/2022] [Indexed: 11/18/2022] Open
Abstract
Giardiasis is a diarrheal disease caused by the unicellular parasite Giardia intestinalis, for which metronidazole is the main treatment option. The parasite is dependent on exogenous deoxyribonucleosides for DNA replication and thus is also potentially vulnerable to deoxyribonucleoside analogs. Here, we characterized the G. intestinalis thymidine kinase, a divergent member of the thymidine kinase 1 family that consists of two weakly homologous parts within one polypeptide. We found that the recombinantly expressed enzyme is monomeric, with 100-fold higher catalytic efficiency for thymidine compared to its second-best substrate, deoxyuridine, and is furthermore subject to feedback inhibition by dTTP. This efficient substrate discrimination is in line with the lack of thymidylate synthase and dUTPase in the parasite, which makes deoxy-UMP a dead-end product that is potentially harmful if converted to deoxy-UTP. We also found that the antiretroviral drug azidothymidine (AZT) was an equally good substrate as thymidine and was active against WT as well as metronidazole-resistant G. intestinalis trophozoites. This drug inhibited DNA synthesis in the parasite and efficiently decreased cyst production in vitro, which suggests that it could reduce infectivity. AZT also showed a good effect in G. intestinalis–infected gerbils, reducing both the number of trophozoites in the small intestine and the number of viable cysts in the stool. Taken together, these results suggest that the absolute dependency of the parasite on thymidine kinase for its DNA synthesis can be exploited by AZT, which has promise as a future medication effective against metronidazole-refractory giardiasis.
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Affiliation(s)
- Sascha Krakovka
- Department of Cell and Molecular Biology, BMC, Uppsala University, Uppsala, Sweden
| | - Farahnaz Ranjbarian
- Department of Medical Biochemistry and Biophysics, Umeå University, Umeå, Sweden
| | - Lucas A Luján
- Centro de Investigación y Desarrollo en Immunología y Enfermedades Infecciosas (CIDIE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)/Universidad Católica de Córdoba (UCC), Cordoba, Argentina
| | - Alicia Saura
- Centro de Investigación y Desarrollo en Immunología y Enfermedades Infecciosas (CIDIE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)/Universidad Católica de Córdoba (UCC), Cordoba, Argentina
| | | | | | - Anna Reggenti
- Department of Medical Biochemistry and Biophysics, Umeå University, Umeå, Sweden
| | - Hugo D Luján
- Centro de Investigación y Desarrollo en Immunología y Enfermedades Infecciosas (CIDIE), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)/Universidad Católica de Córdoba (UCC), Cordoba, Argentina
| | - Staffan G Svärd
- Department of Cell and Molecular Biology, BMC, Uppsala University, Uppsala, Sweden.
| | - Anders Hofer
- Department of Medical Biochemistry and Biophysics, Umeå University, Umeå, Sweden.
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Abstract
BACKGROUND Metronidazole has been used to treat a broad range of infections over the decades, and its safety profile has been presumably well studied. However, neurological severe adverse events after prescription and nonprescription use of metronidazole is well recognized but underdiagnosed. CASE PRESENTATION We report the case of a 48-year-old Indian man who presented with unremitting symptoms of peripheral neuropathy along with a silent callosal lesion in the splenium ("boomerang" sign). Because he had visited 3 neurologists previously, there were many targeted and nontargeted investigations, which failed to reach an etiological diagnosis and hence to provide relief. The patient was questioned about a potential neurotoxin exposure, and at this point, he said that he was taking metronidazole for a long time, without any supervision, as an over-the-counter remedy for self-diagnosed "chronic amebiasis." On stopping metronidazole, he recovered gradually. In the sixth month of follow-up, brain magnetic resonance imaging showed disappearance of the callosal lesion and significant improvement in the nerve conduction studies. CONCLUSIONS Clinicians should keep metronidazole toxicity in mind while dealing with a case of cytotoxic lesion of the corpus callosum with splenium involvement and peripheral neuropathy.
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Kinetic and Molecular Docking Studies to Determine the Effect of Inhibitors on the Activity and Structure of Fused G6PD::6PGL Protein from Trichomonas vaginalis. MOLECULES (BASEL, SWITZERLAND) 2022; 27:molecules27041174. [PMID: 35208965 PMCID: PMC8880039 DOI: 10.3390/molecules27041174] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/03/2022] [Accepted: 02/07/2022] [Indexed: 11/17/2022]
Abstract
Trichomoniasis is a sexually transmitted disease with a high incidence worldwide, affecting 270 million people. Despite the existence of a catalog of available drugs to combat this infection, their extensive use promotes the appearance of resistant Trichomonas vaginalis (T. vaginalis), and some side effects in treated people, which are reasons why it is necessary to find new alternatives to combat this infection. In this study, we investigated the impact of an in-house library comprising 55 compounds on the activity of the fused T. vaginalis G6PD::6PGL (TvG6PD::6PGL) protein, a protein mediating the first reaction step of the pentose phosphate pathway (PPP), a crucial pathway involved in the parasite's energy production. We found four compounds: JMM-3, CNZ-3, CNZ-17, and MCC-7, which inhibited the TvG6PD::6PGL protein by more than 50%. Furthermore, we determined the IC50, the inactivation constants, and the type of inhibition. Our results showed that these inhibitors induced catalytic function loss of the TvG6PD::6PGL enzyme by altering its secondary and tertiary structures. Finally, molecular docking was performed for the best inhibitors, JMM-3 and MCC-7. All our findings demonstrate the potential role of these selected hit compounds as TvG6PD::6PGL enzyme selective inhibitors.
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Li L, Qiu Z, Qi Y, Zhao D, Ali I, Sun C, Xu L, Zheng Z, Ma C. AuNPs/NiFe-LDHs-assisted laser desorption/ionization mass spectrometry for efficient analysis of metronidazole and its metabolites in water samples. JOURNAL OF HAZARDOUS MATERIALS 2022; 423:126893. [PMID: 34479085 DOI: 10.1016/j.jhazmat.2021.126893] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/21/2021] [Accepted: 08/10/2021] [Indexed: 06/13/2023]
Abstract
Gold nanoparticles (AuNPs) have been widely used as laser desorption/ionization mass spectrometry (LDI-MS) nanomaterials for the analysis of low-molecular-weight samples. Nickel/iron-layered double hydroxides (NiFe-LDHs) nanosheets can support the anchoring of AuNPs and enhance the ability of desorption/ionization. Their hybrid nanocomposites are expected to produce synergistic effects to improve the performance of LDI-MS. In this work, a novel AuNPs/NiFe-LDHs nanomaterial was synthesized by self-assembly method and characterized based on TEM, SEM, XPS, UV-vis and FTIR-ATR. AuNPs/NiFe-LDHs assisted LDI-TOF MS exhibited higher peak intensity and lower background noise compared with conventional organic matrices. Furthermore, excellent salt and protein tolerance, good repeatability and quantification were observed when MNZ and its metabolites were detected in the range of 1-50 ng·μL-1 (R2 > 0.98), with LODs and LOQs of 0.5 ng·μL-1 and 1 ng·μL-1, respectively. This nanocomposite could also be used for the analysis of some other small molecules, such as antibiotics, sugars, amino acids and pesticides, demonstrating the potential to detect a variety of environmental chemicals. Taken together, the developed method combined the advantages of two nanomaterials and can provide rapid and accurate analysis of MNZ and its metabolites in water samples, as well as some other small molecules.
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Affiliation(s)
- Lingyu Li
- Key Laboratory of Food Processing Technology and Quality Control of Shandong Higher Education Institutes, College of Food Science and Engineering, Shandong Agricultural University, 61 Daizong Street, Tai'an 271018, Shandong, PR China; Key Laboratory for Applied Technology of Sophisticated Analytical Instruments of Shandong Province, Shandong Analysis and Test Center, Qilu University of Technology (Shandong Academy of Sciences), Jinan 250014, Shandong, PR China
| | - Zhichang Qiu
- Key Laboratory of Food Processing Technology and Quality Control of Shandong Higher Education Institutes, College of Food Science and Engineering, Shandong Agricultural University, 61 Daizong Street, Tai'an 271018, Shandong, PR China
| | - Yuanfeng Qi
- School of Environmental and Municipal Engineering, Qingdao University of Technology, Qingdao 266033, Shandong, PR China
| | - Dantong Zhao
- Heze Institute for Food and Drug Control, Heze 274000, Shandong, PR China
| | - Iftikhar Ali
- Department of Chemistry, Karakoram International University, Gilgit-Baltistan, Gilgit 15100, Pakistan
| | - Chenglong Sun
- Key Laboratory for Applied Technology of Sophisticated Analytical Instruments of Shandong Province, Shandong Analysis and Test Center, Qilu University of Technology (Shandong Academy of Sciences), Jinan 250014, Shandong, PR China
| | - Longhua Xu
- Key Laboratory of Food Processing Technology and Quality Control of Shandong Higher Education Institutes, College of Food Science and Engineering, Shandong Agricultural University, 61 Daizong Street, Tai'an 271018, Shandong, PR China
| | - Zhenjia Zheng
- Key Laboratory of Food Processing Technology and Quality Control of Shandong Higher Education Institutes, College of Food Science and Engineering, Shandong Agricultural University, 61 Daizong Street, Tai'an 271018, Shandong, PR China.
| | - Chunxia Ma
- Key Laboratory for Applied Technology of Sophisticated Analytical Instruments of Shandong Province, Shandong Analysis and Test Center, Qilu University of Technology (Shandong Academy of Sciences), Jinan 250014, Shandong, PR China; School of Environmental and Municipal Engineering, Qingdao University of Technology, Qingdao 266033, Shandong, PR China.
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36
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Sharrock AV, Mulligan TS, Hall KR, Williams EM, White DT, Zhang L, Emmerich K, Matthews F, Nimmagadda S, Washington S, Le KD, Meir-Levi D, Cox OL, Saxena MT, Calof AL, Lopez-Burks ME, Lander AD, Ding D, Ji H, Ackerley DF, Mumm JS. NTR 2.0: a rationally engineered prodrug-converting enzyme with substantially enhanced efficacy for targeted cell ablation. Nat Methods 2022; 19:205-215. [PMID: 35132245 PMCID: PMC8851868 DOI: 10.1038/s41592-021-01364-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/29/2021] [Indexed: 11/12/2022]
Abstract
Transgenic expression of bacterial nitroreductase (NTR) enzymes sensitizes eukaryotic cells to prodrugs such as metronidazole (MTZ), enabling selective cell-ablation paradigms that have expanded studies of cell function and regeneration in vertebrates. However, first-generation NTRs required confoundingly toxic prodrug treatments to achieve effective cell ablation, and some cell types have proven resistant. Here we used rational engineering and cross-species screening to develop an NTR variant, NTR 2.0, which exhibits ~100-fold improvement in MTZ-mediated cell-specific ablation efficacy, eliminating the need for near-toxic prodrug treatment regimens. NTR 2.0 therefore enables sustained cell-loss paradigms and ablation of previously resistant cell types. These properties permit enhanced interrogations of cell function, extended challenges to the regenerative capacities of discrete stem cell niches, and novel modeling of chronic degenerative diseases. Accordingly, we have created a series of bipartite transgenic reporter/effector resources to facilitate dissemination of NTR 2.0 to the research community.
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Affiliation(s)
- Abigail V Sharrock
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Timothy S Mulligan
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Kelsi R Hall
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - Elsie M Williams
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand
| | - David T White
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Liyun Zhang
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Kevin Emmerich
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Frazer Matthews
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Saumya Nimmagadda
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Selena Washington
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Katherine D Le
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Danielle Meir-Levi
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Olivia L Cox
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
| | - Meera T Saxena
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
- Luminomics, Baltimore, MD, USA
| | - Anne L Calof
- Department of Anatomy and Neurobiology, University of California, Irvine, CA, USA
- Department of Developmental and Cell Biology, University of California, Irvine, CA, USA
- Center for Complex Biological Systems, University of California, Irvine, CA, USA
| | - Martha E Lopez-Burks
- Department of Developmental and Cell Biology, University of California, Irvine, CA, USA
- Center for Complex Biological Systems, University of California, Irvine, CA, USA
| | - Arthur D Lander
- Department of Developmental and Cell Biology, University of California, Irvine, CA, USA
- Center for Complex Biological Systems, University of California, Irvine, CA, USA
| | - Ding Ding
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hongkai Ji
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David F Ackerley
- School of Biological Sciences, Victoria University of Wellington, Wellington, New Zealand.
- Centre for Biodiscovery and Maurice Wilkins Centre for Molecular Biodiscovery, Victoria University of Wellington, Wellington, New Zealand.
| | - Jeff S Mumm
- Department of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA.
- The Center for Nanomedicine, Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA.
- The Solomon H. Snyder Department of Neuroscience, Johns Hopkins University, Baltimore, MD, USA.
- Department of Genetic Medicine, McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.
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Rajabi S, Nasiri A, Hashemi M. Enhanced activation of persulfate by CuCoFe2O4@MC/AC as a novel nanomagnetic heterogeneous catalyst with ultrasonic for metronidazole degradation. CHEMOSPHERE 2022; 286:131872. [PMID: 34411932 DOI: 10.1016/j.chemosphere.2021.131872] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/20/2021] [Accepted: 08/10/2021] [Indexed: 06/13/2023]
Abstract
In this study, the degradation of Metronidazole (MNZ) using CuCoFe2O4@MC/AC catalyst synthesized by microwave-assisted method, as an efficient activator for persulfate (PS) in the presence of ultrasonic (US: 60 kHz) was investigated. X-ray powder diffraction (XRD), Field emission scanning electron microscope (FESEM), Energy dispersive spectroscopy (EDS)-Mapping and Line scan, Fourier transform infrared spectroscopy (FTIR), Vibrating-sample magnetometer (VSM), and Thermal gravimetric analysis (TGA) were conducted to characterize the structure of CuCoFe2O4@MC/AC catalyst and then the catalyst dose, PS dose, MNZ concentration, and pH parameters were optimized. The maximum MNZ degradation of 93.78 % was achieved after 15 min reaction at the optimized operation conditions: 0.4 g L-1 of catalyst, 6 mM of PS, 5 mg L-1 of MNZ, and pH of 3. The removal efficiency of Total Organic Carbon (TOC) was 87.5 % under optimal conditions. According to kinetic equations, it was found that the MNZ degradation followed both kinetics (pseudo-first-order and Langmuir-Hinshelwood) based on the coefficient of determination (R2) of 0.949, 0.9716, 0.9073, 0.9721, and 0.9662 at concentrations of 5, 10, 15, 20, and 30, respectively. The surface reaction rate constant (Kc) and the adsorption equilibrium constant (KL-H) of the Langmuir-Hinshelwood model were 0.81 (mg L-1 min-1) and 2.184 (L mg-1), respectively. The free radical scavenging experiments were conducted to illustration the proposed mechanism, which shown that the SO4-• was the predominant radicals involved in MNZ degradation. Finally, the regeneration of the catalyst was investigated and showed that after five cycles of use and regeneration by chemical and thermal methods, this catalyst has acceptable chemical stability.
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Affiliation(s)
- Saeed Rajabi
- Environmental Health Engineering Research Center, Kerman University of Medical Sciences, Kerman, Iran; Department of Environmental Health Engineering, Faculty of Public Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Alireza Nasiri
- Environmental Health Engineering Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Majid Hashemi
- Environmental Health Engineering Research Center, Kerman University of Medical Sciences, Kerman, Iran; Department of Environmental Health Engineering, Faculty of Public Health, Kerman University of Medical Sciences, Kerman, Iran.
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Quickfall D, Daneman N, Dmytriw AA, Juurlink DN. Neurotoxicité du métronidazole. CMAJ 2021; 193:E1928. [PMID: 34930773 PMCID: PMC8687503 DOI: 10.1503/cmaj.201671-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Danica Quickfall
- Département de médecine (Quickfall, Daneman, Juurlink), Centre des sciences de la santé Sunnybrook; Départements de médecine et de pédiatrie (Quickfall, Daneman, Juurlink), Université de Toronto; Institut de recherche en services de santé (ICES) (Daneman, Juurlink), Toronto, Ont.; Programme neuroendovasculaire (Dmytriw), Hôpital général du Massachusetts, Faculté de médecine de l'Université Harvard, Boston, Mass.; Centre antipoison de l'Ontario (Juurlink), Toronto, Ont
| | - Nick Daneman
- Département de médecine (Quickfall, Daneman, Juurlink), Centre des sciences de la santé Sunnybrook; Départements de médecine et de pédiatrie (Quickfall, Daneman, Juurlink), Université de Toronto; Institut de recherche en services de santé (ICES) (Daneman, Juurlink), Toronto, Ont.; Programme neuroendovasculaire (Dmytriw), Hôpital général du Massachusetts, Faculté de médecine de l'Université Harvard, Boston, Mass.; Centre antipoison de l'Ontario (Juurlink), Toronto, Ont
| | - Adam A Dmytriw
- Département de médecine (Quickfall, Daneman, Juurlink), Centre des sciences de la santé Sunnybrook; Départements de médecine et de pédiatrie (Quickfall, Daneman, Juurlink), Université de Toronto; Institut de recherche en services de santé (ICES) (Daneman, Juurlink), Toronto, Ont.; Programme neuroendovasculaire (Dmytriw), Hôpital général du Massachusetts, Faculté de médecine de l'Université Harvard, Boston, Mass.; Centre antipoison de l'Ontario (Juurlink), Toronto, Ont
| | - David N Juurlink
- Département de médecine (Quickfall, Daneman, Juurlink), Centre des sciences de la santé Sunnybrook; Départements de médecine et de pédiatrie (Quickfall, Daneman, Juurlink), Université de Toronto; Institut de recherche en services de santé (ICES) (Daneman, Juurlink), Toronto, Ont.; Programme neuroendovasculaire (Dmytriw), Hôpital général du Massachusetts, Faculté de médecine de l'Université Harvard, Boston, Mass.; Centre antipoison de l'Ontario (Juurlink), Toronto, Ont.
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40
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Affiliation(s)
- Danica Quickfall
- Department of Medicine (Quickfall, Daneman, Juurlink), Sunnybrook Health Sciences Centre; Departments of Medicine and Paediatrics (Quickfall, Daneman, Juurlink), University of Toronto; Institute for Clinical Evaluative Sciences (ICES) (Daneman, Juurlink), Toronto, Ont.; Neuroendovascular Program (Dmytriw), Massachusetts General Hospital, Harvard Medical School, Boston, Mass.; Ontario Poison Centre (Juurlink), Toronto, Ont
| | - Nick Daneman
- Department of Medicine (Quickfall, Daneman, Juurlink), Sunnybrook Health Sciences Centre; Departments of Medicine and Paediatrics (Quickfall, Daneman, Juurlink), University of Toronto; Institute for Clinical Evaluative Sciences (ICES) (Daneman, Juurlink), Toronto, Ont.; Neuroendovascular Program (Dmytriw), Massachusetts General Hospital, Harvard Medical School, Boston, Mass.; Ontario Poison Centre (Juurlink), Toronto, Ont
| | - Adam A Dmytriw
- Department of Medicine (Quickfall, Daneman, Juurlink), Sunnybrook Health Sciences Centre; Departments of Medicine and Paediatrics (Quickfall, Daneman, Juurlink), University of Toronto; Institute for Clinical Evaluative Sciences (ICES) (Daneman, Juurlink), Toronto, Ont.; Neuroendovascular Program (Dmytriw), Massachusetts General Hospital, Harvard Medical School, Boston, Mass.; Ontario Poison Centre (Juurlink), Toronto, Ont
| | - David N Juurlink
- Department of Medicine (Quickfall, Daneman, Juurlink), Sunnybrook Health Sciences Centre; Departments of Medicine and Paediatrics (Quickfall, Daneman, Juurlink), University of Toronto; Institute for Clinical Evaluative Sciences (ICES) (Daneman, Juurlink), Toronto, Ont.; Neuroendovascular Program (Dmytriw), Massachusetts General Hospital, Harvard Medical School, Boston, Mass.; Ontario Poison Centre (Juurlink), Toronto, Ont.
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41
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Tang R, Liang J, Li Y, Wu T, Zhang Y, Ma Y, Liu X. Ornidazole-Induced Recurrent Encephalopathy in a Chinese Man: A Rare Case Report and Literature Review. Front Neurol 2021; 12:706094. [PMID: 34566850 PMCID: PMC8458754 DOI: 10.3389/fneur.2021.706094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/05/2021] [Indexed: 12/01/2022] Open
Abstract
Ornidazole-induced encephalopathy (OIE) is seldom seen in the clinic. In this study, we report a new case of a patient who had taken 1,000 mg ornidazole daily for nearly 4 years because of suspected diarrhea and proctitis and presented with subacute symptoms such as unsteady gait, slurred speech, and psychiatric disorder. These symptoms were significantly relieved 3 days after the patient stopped taking ornidazole. When he took this medicine again, however, similar symptoms occurred 4 months later, which were again reduced after 4 days of drug discontinuation. After the second onset, abnormal signals were identified around the aqueduct of the midbrain, around the fourth ventricle, and in the dentate nuclei of the cerebellum bilaterally. After 9 days of drug discontinuation, lesions disappeared in the magnetic resonance imaging (MRI) results. According to the clinical manifestations, imaging features, and the reduced symptoms after drug withdrawal, we clinically diagnosed the patient with OIE. This paper also reviews the literature on OIE. Only five cases (including our case) have been reported, all of whom presented with cerebellar ataxia and dysarthria and three with additional mental symptoms such as agitation and irritability. All five patients had abnormal lesions in the dentate nucleus of the cerebellum bilaterally, among whom four also had lesions in the corpus callosum and three around the periaqueduct of the midbrain. After withdrawal of ornidazole, the symptoms in all patients vanished or were alleviated, and three of them showed reduced or disappeared lesions in a head MRI reexamination. Overall, OIE has rarely been reported. Our case report and literature review show that the lesions in the cerebellum, corpus callosum, and brainstem can be reversed. The main manifestations of the lesions—cerebellar ataxia, dysarthria, and mental symptoms—quickly weaken or disappear after drug withdrawal, with good prognosis. Nevertheless, clear pathogenesis has yet to be further investigated.
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Affiliation(s)
- Rong Tang
- Department of Neurology, Zhongshan Hospital, Fudan University (Xiamen Branch), Xiamen, China.,Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jia Liang
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuanfang Li
- Department of Neurology, Zhongshan Hospital, Fudan University (Xiamen Branch), Xiamen, China.,Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tingting Wu
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuhao Zhang
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yu Ma
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xu Liu
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China
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42
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Starrs ME, Yenigun OM. Metronidazole, an Uncommon Cause of Dizziness and Ataxia in the Emergency Department: A Case Report. Clin Pract Cases Emerg Med 2021; 5:239-241. [PMID: 34437014 PMCID: PMC8143839 DOI: 10.5811/cpcem.2021.3.52046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/19/2021] [Indexed: 11/24/2022] Open
Abstract
Introduction Metronidazole, a nitroimidazole antibiotic, is a well-known antibacterial and antiprotozoal agent that is generally well tolerated without many serious side effects. Most adverse reactions affect the gastrointestinal or genitourinary system, but the central nervous system may also be afflicted. In addition to headache and dizziness, cerebellar dysfunction can occur with metronidazole use. Case Report We discuss the clinical presentation and imaging findings of metronidazole-induced encephalopathy in a 12-year-old male. The patient had a history of Crohn’s disease and chronic Clostridium difficile infection for which he had received metronidazole for approximately 75 days prior to arrival to a local emergency department (ED). He presented with five days of progressive vertigo, nausea, vomiting, and ataxia. Subsequent magnetic resonance imaging showed symmetric hyperintense dentate nuclei lesions, characteristic of metronidazole-induced encephalopathy. The patient’s symptoms improved rapidly after cessation of metronidazole, and his symptoms had completely resolved by discharge on hospital day two. Conclusion Metronidazole-induced encephalopathy is a rare cause of vertigo and ataxia that can lead to permanent sequela if not identified and treated promptly. Thus, it is important for physicians to keep this diagnosis in mind when evaluating patients on metronidazole who present to the ED with new neurologic complaints.
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Affiliation(s)
- Mary E Starrs
- Stanford University Medical Center, Department of Emergency Medicine, Palo Alto, California
| | - Onur M Yenigun
- Stanford University Medical Center, Department of Emergency Medicine, Palo Alto, California
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43
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Faraji Dana H, Shojaei Arani L, Faraji A, Bahmani K. A case report of toxic leukoencephalopathy induced by metronidazole in a woman with surgical site infection. Clin Case Rep 2021; 9:e04635. [PMID: 34430007 PMCID: PMC8365004 DOI: 10.1002/ccr3.4635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/07/2021] [Accepted: 07/06/2021] [Indexed: 11/05/2022] Open
Abstract
Metronidazole may rarely cause encephalopathy and neuropathy. In this study, we report a 30-year-old post-partum, ex-addicted female with leukoencephalopathy due to metronidazole.
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Affiliation(s)
- Hoorvash Faraji Dana
- Clinical Toxicology FellowshipEmergency DepartmentAlborz University of Medical ScienceKarajIran
| | - Lida Shojaei Arani
- Clinical Toxicology FellowshipEmergency DepartmentAlborz University of Medical ScienceKarajIran
| | - Ali Faraji
- Student Research CommitteeSchool of MedicineAlborz University of Medical SciencesKarajIran
| | - Kiumars Bahmani
- Department of Pharmacology and ToxicologySchool of PharmacyShahid Beheshti University of Medical ScienceTehranIran
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Xiao M, Huang X. Unmasking antibiotic-associated neurological disorders: The underminer in Intensive Care Unit. J Clin Neurosci 2021; 91:131-135. [PMID: 34373018 DOI: 10.1016/j.jocn.2021.06.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/16/2021] [Accepted: 06/22/2021] [Indexed: 12/26/2022]
Abstract
Psychosis is a common and intractable disorder of hospitalization, especially in patients hospitalized in Intensive Care Unit (ICU). Along with the widely use of multiple antibiotics in community-acquired infection and hospital-acquired infection, the occurrence of antibiotic-associated neurological disorders has become more frequently. However, antibiotic neurotoxicity is often overlooked or misinterpreted. In this review, we summarized the neurological disorders caused by antibacterial agent usage and firstly systematically formulated the pathogenesis of antibiotic-associated neurotoxic reactions. Precautions of the complications are critical in preventing serious clinical outcome as the inducement is curable. Regular neurological physical examination, electroencephalogram (EEG) examination, lumbar puncture and therapeutic drug monitoring closely are essential for early diagnosis and differential diagnosis.
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Affiliation(s)
- Minjia Xiao
- Department of Neurology, The First People's Hospital of Yueyang, Yueyang, China
| | - Xiang Huang
- Department of Neurology, The First People's Hospital of Yueyang, Yueyang, China.
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45
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Green synthesis of silver nanoparticle using goniothalamus wightii on graphene oxide nanocomposite for effective voltammetric determination of metronidazole. SENSING AND BIO-SENSING RESEARCH 2021. [DOI: 10.1016/j.sbsr.2021.100425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Cappellari AM, Rossetti D, Avignone S, Scola E, Di Cesare A. Pediatric Metronidazole-Induced Encephalopathy: A Case Report and Review of the Literature. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1716347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractMetronidazole-induced encephalopathy is a rare toxic encephalopathy secondary to the common use to this antimicrobial drug. It has been reported mainly in adult patients but only rarely in children. Owing to possible devastating complication of this disease, clinicians should have a higher index of suspicion for encephalopathic patients on metronidazole therapy. Here, we report a 5-month-old infant with metronidazole-induced encephalopathy presenting with nonconvulsive status epilepticus. A review of the literature in pediatric, as well as adult metronidazole-induced encephalopathy, is also provided.
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Affiliation(s)
- Alberto M. Cappellari
- Department of Neuroscience, Fondazione Scientific Institute for Research, Hospitalization and Healthcare Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | | | - Sabrina Avignone
- Department of Neuroradiology, Fondazione Scientific Institute for Research, Hospitalization and Healthcare Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Elisa Scola
- Department of Neuroradiology, Fondazione Scientific Institute for Research, Hospitalization and Healthcare Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Antonio Di Cesare
- Department of Pediatric Surgery, Fondazione Scientific Institute for Research, Hospitalization and Healthcare Ca' Granda, Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
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Lala VG, Bobat B, Haagensen M, Kathan P, Mahomed A. Metronidazole-induced encephalopathy. SA J Radiol 2021; 25:2016. [PMID: 33824746 PMCID: PMC8008077 DOI: 10.4102/sajr.v25i1.2016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 12/01/2020] [Indexed: 11/01/2022] Open
Abstract
Metronidazole is a widely used antibacterial and antiprotozoal agent for a number of conditions. Whilst its more common gastrointestinal side effects are well known, neurotoxicity remains under-recognised. Both central and peripheral neurological side effects have been described. This report describes a case of radiologically confirmed metronidazole-induced cerebellar ataxia in a cirrhotic patient with a review of the literature. Awareness of this side effect is essential for prompt recognition as early drug withdrawal leads to resolution in the majority of cases.
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Affiliation(s)
- Vikash G Lala
- Department of Gastroenterology, Faculty Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Bilal Bobat
- Department of Gastroenterology, Faculty Internal Medicine, Wits Donald Gordan Medical Centre, Johannesburg, South Africa
| | - Mark Haagensen
- Department of Radiology, Faculty of Health Sciences, Wits Donald Gordan Medical Centre, Johannesburg, South Africa
| | - Prakash Kathan
- Department of Neurology, Faculty of Health Sciences, Wits Donald Gordan Medical Centre, Johannesburg, South Africa
| | - Adam Mahomed
- Department of Gastroenterology, Faculty Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
- Department of Gastroenterology, Faculty Internal Medicine, Wits Donald Gordan Medical Centre, Johannesburg, South Africa
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48
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Shirley DA, Sharma I, Warren CA, Moonah S. Drug Repurposing of the Alcohol Abuse Medication Disulfiram as an Anti-Parasitic Agent. Front Cell Infect Microbiol 2021; 11:633194. [PMID: 33777846 PMCID: PMC7991622 DOI: 10.3389/fcimb.2021.633194] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/18/2021] [Indexed: 01/24/2023] Open
Abstract
Parasitic infections contribute significantly to worldwide morbidity and mortality. Antibiotic treatment is essential for managing patients infected with these parasites since control is otherwise challenging and there are no vaccines available for prevention. However, new antimicrobial therapies are urgently needed as significant problems exist with current treatments such as drug resistance, limited options, poor efficacy, as well as toxicity. This situation is made worse by the challenges of drug discovery and development which is costly especially for non-profitable infectious diseases, time-consuming, and risky with a high failure rate. Drug repurposing which involves finding new use for existing drugs may help to more rapidly identify therapeutic candidates while drastically cutting costs of drug research and development. In this perspective article, we discuss the importance of drug repurposing, review disulfiram pharmacology, and highlight emerging data that supports repurposing disulfiram as an anti-parasitic, exemplified by the major diarrhea-causing parasite Entamoeba histolytica.
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Affiliation(s)
- Debbie-Ann Shirley
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Virginia, Charlottesville, VA, United States
| | - Ishrya Sharma
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Cirle A Warren
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Shannon Moonah
- Division of Infectious Diseases & International Health, Department of Medicine, University of Virginia, Charlottesville, VA, United States
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49
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John KJ, P Pillai D, Pillai V, John JK. Metronidazole-induced reversible cerebellar dysfunction. BMJ Case Rep 2021; 14:14/2/e239227. [PMID: 33526534 PMCID: PMC7852976 DOI: 10.1136/bcr-2020-239227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
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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Affiliation(s)
- Kevin John John
- Department of Neurology, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Deep P Pillai
- Department of Neurology, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Vinod Pillai
- Department of Gastrointestinal and Hepatobiliary Surgery, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - John K John
- Department of Neurology, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
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50
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Mimura Y, Yahiro M, Masumoto M, Fukui R, Okamoto R, Aichi M, Mihara Y, Ueda T, Takesue Y, Ikawa K, Morikawa N, Kuragano T. The pharmacokinetics of oral metronidazole in patients with metronidazole‐induced encephalopathy undergoing maintenance hemodialysis. Hemodial Int 2020; 24:528-533. [DOI: 10.1111/hdi.12857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 06/15/2020] [Accepted: 07/09/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Yasuyuki Mimura
- Department of Internal Medicine, Division of Kidney and Dialysis Hyogo College of medicine Hospital Hyogo Japan
| | - Mana Yahiro
- Department of Internal Medicine, Division of Kidney and Dialysis Hyogo College of medicine Hospital Hyogo Japan
| | - Miwa Masumoto
- Department of Internal Medicine, Division of Kidney and Dialysis Hyogo College of medicine Hospital Hyogo Japan
| | - Risako Fukui
- Department of Internal Medicine, Division of Kidney and Dialysis Hyogo College of medicine Hospital Hyogo Japan
| | - Rina Okamoto
- Department of Internal Medicine, Division of Kidney and Dialysis Hyogo College of medicine Hospital Hyogo Japan
| | - Makoto Aichi
- Department of Internal Medicine, Division of Kidney and Dialysis Hyogo College of medicine Hospital Hyogo Japan
| | - Yuki Mihara
- Department of Internal Medicine Social Welfare Organization Saiseikai Imperial Gift Foundation, Inc. Saiseikai Hyogo‐ken Hospital Hyogo Japan
| | - Takashi Ueda
- Department of Infection Control and Prevention Hyogo College of Medicine Hyogo Japan
| | - Yoshio Takesue
- Department of Infection Control and Prevention Hyogo College of Medicine Hyogo Japan
| | - Kazuro Ikawa
- Department of Clinical Pharmacotherapy Hiroshima University Hiroshima Japan
| | - Norifumi Morikawa
- Department of Clinical Pharmacotherapy Hiroshima University Hiroshima Japan
| | - Takahiro Kuragano
- Department of Internal Medicine, Division of Kidney and Dialysis Hyogo College of medicine Hospital Hyogo Japan
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