Disclosures: Justin L. Weppner, DO: No financial relationships or conflicts of interest

Case Diagnosis: Metronidazole-induced cerebellar toxicity

Case Description: A 58-year-old female presented to the acute hospital after being found unresponsive. Brain magnetic resonance imaging (MRI) was notable for multifocal, diffusion restricting, rim-enhancing lesions, and she was treated with vancomycin, cefepime, and metronidazole for micro-abscesses. Repeat MRI after initiation of antibiotics showed a decreasing size of the lesions, and she was discharged with plans to complete a seven-week antibiotic course. She returned two weeks after discharge with generalized weakness, inability to walk, myalgias, and decreased oral intake. Her physical exam was significant for right-sided weakness and ataxia. An MRI brain was obtained, which showed interval improvement of the rim-enhancing lesions. However, there was interval development of symmetric enhanced T2/FLAIR signal in the bilateral dentate nuclei consistent with metronidazole-induced cerebellar toxicity, and metronidazole was discontinued.

Setting: Academic free-standing rehabilitation hospitalAssessment/

Results: The patient was discharged to an inpatient rehabilitation facility. On admission to rehabilitation, she was noted to be dependent for activities of daily living (ADLs), moderate assistance for transfers, and ambulated up to ten feet with a front wheeled walker with a two-person assist. The patient was enrolled in an intensive therapy program focused on balance, gait, ADL retraining, and muscle strengthening. At discharge, she was independent for ADLs and was able to ambulate 160 feet independently with a rolling walker.

Discussion: Metronidazole-induced cerebellar toxicity is a rare complication with varied symptoms including, weakness, ataxia, and encephalopathy. It is associated with characteristic MRI findings of signal enhancement in the dentate nuclei. Following discontinuation of metronidazole therapy, improvement in structural lesions and clinical improvement is often observed, making these patients excellent inpatient neurorehabilitation candidates.

Conclusion: Cerebellar toxicity is a rare adverse effect of metronidazole therapy. These patients are expected to make excellent functional gains, with most making a near-complete recovery with discontinuation of metronidazole combined with a comprehensive rehabilitation approach.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/case-report-regaining-function-after-metronidazole-induced-cerebellar-toxicity/