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Metronidazole/ustekinumab Ataxia, parkinsonism and encephalopathy: case report

A 41-year-old man developed ataxia, parkinsonism and encephalopathy secondary drug toxicity during treatment with metronidazole for infected perianal ulcers. Additionally, ustekinumab contributed to the encephalopathy [not all indications stated; dosages and routes not stated]. The man, who had Crohn’s disease, presented with a 2-week history of dysarthria, slowness of movement, progressive gait instability and lower extremity numbness. He had undergone total colonic resection 17 years prior. He had been receiving metronidazole and ciprofloxacin since 8 years for infected perianal ulcers. Concomitantly, he had been receiving ustekinumab (for 1 year) and unspecified multivitamin. At presentation, he had bradykinesia, hypophonia, gait ataxia and dysdiadochokinesia. Further examinations revealed absence of Achille’s tendon reflexes bilaterally, symmetric length-dependent sensory neuropathy along with loss of vibration and pin-prick in the distal lower extremities. His gait was wide based and bradykinetic. Further, brain MRI demonstrated symmetric T2-FLAIR hyperintense lesions involving the bilateral dentate nuclei and superior olivary nuclei in the dorsal pons and bilateral posterior putamen, indicating metronidazole-induced encephalopathy. Based on these findings, a diagnosis of ataxia and mild parkinsonism secondary to metronidazole toxicity was confirmed. The man’s treatment with metronidazole was stopped. His bradykinesia and ataxia improved over the following week, while the remaining symptoms resolved three weeks following drug discontinuation. Subsequent MRI 6 months following metronidazole discontinuation showed complete resolution of prior brain abnormalities; however, evolution of subtle diffuse T2 FLAIR hyperintensity within the splenium of the corpus callosum and the adjacent white matter of parietal lobes were observed. These neuroimaging findings were attributed to the delayed onset of prior metronidazole toxicity and secondary to ustekinumab therapy. Muir RT, et al. Ataxia and parkinsonism in metronidazole neurotoxicity. Canadian Journal of Neurological Sciences : 1-7, 20 Jul 2020. Available from: URL: http:// doi.org/10.1017/cjn.2020.156

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Reactions 22 Aug 2020 No. 1818