A case of methylprednisolone treatment for metronidazole-induced encephalopathy

Metronidazole-Induced Encephalopathy With Probable Crohn Encephalitis: A Case Report

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.

Metronidazole-induced encephalopathy in a patient with cirrhosis

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.

Methylprednisolone 100 mg tablet formulation with pea protein: Experimental Approaches over intestinal permeability and cytotoxicity

OBJECTIVE

This study was carried out to transform the hydrolysed pea protein into a pharmaceutical tablet form by masking methylprednisolone.

SIGNIFICANCE

This study provides some crucial contributions in showing how functional excipients such as pea protein, which are generally used in food industries, can be used in pharmaceutical product formulations and their effects.

METHODS

Methylprednisolone was formulated using spray drying technology. Design Expert Software (Version 13) was used for the statistical analysis. The in vitro cytotoxic effects for NIH/3T3 mouse fibroblast cells were investigated by XTT cell viability assay. HPLC was used to analyse the Caco-2 permeability studies and dissolution tests.

RESULTS

The optimum formulation was evaluated against the reference product by performing cytotoxicity and cell permeability studies. According to our test results, Papp (apparent permeability) values of Methylprednisolone were measured around 3 x 10-6 cm/s and Fa (fraction absorbed) values around 30%.These data indicate that Methylprednisolone HCl has "moderate permeability" and our study confirmed that it could have belonged to BCS Class II-IV since both low solubility and moderate permeability.In conclusion, the findings offer valuable information to guide and inform the use of pea protein in pharmaceutical formulations.Significant effects on methylprednisolone tablet formulation designed with the philosophy of quality by design (QbD) of pea protein have been demonstrated by both in vitro and cell studies.

Pharmaceutical activity of a synthetic heterocyclic (C15H12N5OCL) compound on Entamoeba histolytica and Giardia lamblia

Abstract: Background: Intestinal parasites are among the most important infectious agents with an impact on human health. Indeed, in the lack of an available treatment option, these parasites could constitute a real health problem in the population. Aim: In the present study, we investigated the effect of a synthetic heterocyclic compound on two intestinal parasites (Entamoeda histolytica and Gardia lamblia). Methods: The parasite isolates tested were collected from outpatients at the General Pediatric Hospital in Kirkuk, Iraq, between September 2019 and January 2020. Thus, we studied the in vivo and in vitro pharmaceutical activity of the ingredient on both parasites. The toxicological effects of the substance on some blood parameters and liver and kidney function tests were also studied. Results: After five days of treatment, the drug's in vivo action on G. lamblia resulted in an inhibition rate of 88.2 percent at a dose of 1 mg/kg. On the other hand, we observed that the influence of this synthetic substance on cultured E. histolytica was very close to the metronidazole effect. The maximum result was at a concentration of 1 g/ml and was obtained after 72 hours of incubation with an inhibition rate of 89.4%. The substance did not affect the blood parameters or the studied liver and kidney functions. Conclusion: It can be concluded that this substance is highly effective against both E. histolytica and G. lamblia, and that it has no toxic effects on the studied parameters. Therefore, it could be a promising pharmacophore for intestinal protozoan parasites including E. histolytica and G. lamblia and an alternative or competitor to the current medications available.

Metronidazole-Induced Encephalopathy in a 16-Year-Old Girl with Crohn’s Disease: Case Report and Review of the Pediatric Literature

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.

Exacerbation of Mania due to Metronidazole in a Bipolar Disorder

Bipolar disorder is a mental health disorder where the patient experiences extreme shifts in mood marked by depression, mania, or hypomania. It affects their overall daily life activities and sleep patterns. This case report is of a 74-year-old female patient with bipolar disorder who experienced a manic episode after initiation of antibiotics to treat gallbladder perforation with abscess formation. The patient's past medical history included Parkinson's disease, diabetes mellitus, bipolar disorder, and acalculous cholecystitis. The patient required hospitalization for a cholecystostomy tube insertion for drainage. During hospitalization, the patient was started on empiric treatment with broad-spectrum antibiotics, including piperacillin/tazobactam and metronidazole. The patient remained stable during the inpatient stay and was discharged home one week later. She was prescribed cefuroxime and metronidazole to complete a 2-week duration of antibiotics. However, upon discharge, she developed manic symptoms, including lack of need to sleep, excessive talking, and severe agitation. Upon assessment, the psychiatric team decided to hold metronidazole as it has an adverse effect of mania as evidenced in drug information resources. The patient started to show immediate recovery from the symptoms with complete resolution of manic symptoms on the 3^rd day following the discontinuation of metronidazole. This case emphasizes the increased need for vigilance in bipolar patients upon prescribing metronidazole. Also, further research is needed to predict the time to onset of manic symptoms and improvement in patient symptoms upon drug discontinuation.

Metronidazole, an Uncommon Cause of Dizziness and Ataxia in the Emergency Department: A Case Report

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.

Unmasking antibiotic-associated neurological disorders: The underminer in Intensive Care Unit

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.

Metronidazole-induced reversible cerebellar dysfunction

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.